What’s New in the
Patient Safety World
December 2017
ECRI’s Top 10
Health Technology Hazards for 2018
ECRI Institute has
released its annual Top 10 list for health technology hazards for 2018 (ECRI 2017). They are:
- Cybersecurity threats in health care delivery and patient
endangerment
- Endoscope reprocessing
- Bed and stretcher mattress contamination
- Secondary alarm notification systems
- Medical device cleaning methods
- Electrosurgical electrode pencil handling
- Digital imaging tools to control radiation
- Bar-coded medication system workarounds
- Networked medical devices and information systems
- Enteral feeding tubing erroneously connected to patient lines
Most of these have
been on ECRI’s lists at some time in the past. But the cybersecurity
issue really vaulted to the top of the list this year after hospital systems
ground to a halt after ransomware attacks. HealthLeaders
Media (Pecci
2017) noted six points for leadership to consider
from Juuso Leinonen, senior project engineer for ECRI
Institute's Health Devices Group:
- Define organization-specific goals to improve security and develop a
practical plan.
- Prioritize resource allocation, including money and people power.
- Conduct real-life exercises and drills that consider overall
organizational response and what the clinical workflow would be in the
case of an attack (including the chance of reverting to a paper workflow).
- Create a complete and detailed inventory of assets that are
connected to the hospital networks.
- Involve everyone in the organization, which can be as small as
reminding everyone not to click on suspicious emails.
- Institute a plan for identifying when software updates are
available, confirming whether a device can be safely updated, and applying
the updates in a timely manner.
Again on this year’s list is the one regarding
secondary alarm notification systems. You’ll recall in our February 9,
2016 Patient Safety Tip of the Week “It
was just a matter of time…”
we described a case in which the alarm notification went out to a healthcare
worker who was not assigned to that patient rather than to the correct person.
Electrosurgical electrode pencil handling also made this year’s list. Proper use of
safety holsters for active-electrode pencils is critical to avoid inadvertent
activation of ESU pencils. We’ve done numerous columns on the role of
electrocautery devices causing both surgical fires and iatrogenic burns. Our September
5, 2017 Patient Safety Tip of the Week “Another
Iatrogenic Burn” discussed
in detail issues related to electrocautery devices.
We’ll let you read about these and all the others in the ECRI document itself. You can download ECRI Institute’s Top 10 Health Technology Hazards for 2018 for free at the ECRI site.
References:
ECRI Institute. Top 10 Health Technology Hazards for 2018. ECRI Institute. November 2017
https://www.ecri.org/Pages/2018-Hazards.aspx
Pecci AW. 6 Things Healthcare Execs Should Do to Prepare for Cyber Threats. HealthLeaders Media 2017; November 21, 2017
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