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Whats New in the
Patient Safety World
February 2023
ECRI Top 10 Health
Technology Hazards for 2023
Each year ECRI Institute publishes
a list of its Top 10 Technology Hazards. The List for 2023 (ECRI
2023):
1.
Gaps in Recalls for At-Home Medical Devices Cause
Patient Confusion and Harm
2.
Growing Number of Defective Single-Use Medical Devices
Puts Patients at Risk
3.
Inappropriate Use of Automated Dispensing Cabinet
Overrides Can Result in Medication Errors
4.
Undetected Venous Needle Dislodgement or
Access-Bloodline Separation during Hemodialysis Can Lead to Death
5.
Failure to Manage Cybersecurity Risks Associated with
Cloud-Based Clinical Systems Can Result in Care Disruptions
6.
Inflatable Pressure Infusers Can Deliver Fatal Air
Emboli from IV Solution Bags
7.
Confusion Surrounding Ventilator Cleaning and
Disinfection Requirements Can Lead to Cross-Contamination
8.
Common Misconceptions about Electrosurgery Can Lead to
Serious Burns
9.
Overuse of Cardiac Telemetry Can Lead to Clinician
Cognitive Overload and Missed Critical Events
10. Underreporting
Device-Related Issues May Risk Recurrence
We recommend you go to the full ECRI report for details on
all 10 items. But we will comment on several of these that weve emphasized in
many of our columns.
Item #4 Undetected Venous Needle Dislodgement or
Access-Bloodline Separation during Hemodialysis Can Lead to Death was one
of our earliest warnings. Our March 26, 2007 Patient Safety Tip of the Week Alarms Should Point to the
Problem described an unfortunate case where inappropriate response
to a low-pressure alarm in a dialysis patient led to cardiac arrest due to
massive blood loss. That was not an isolated case. We went on to discuss almost
identical cases in our Patient Safety Tips of the Week for April
25, 2017 Dialysis and Alarm Fatigue, December 10, 2019 Dialysis Line Dislodgements, and December 7, 2021 The Hidden Dialysis Catheter.
It is essential that vascular access sites be secure and visible and that any
alarms focus the responders attention on that site.
Item #9 Overuse of Cardiac Telemetry has been the
subject of our columns listed below and the topic of our February 7, 2023
Patient Safety Tip of the Week Reducing
Unnecessary Telemetry.
Item #3 Inappropriate Use of ADC Overrides is the
subject of our many columns on safety issues related to automated dispensing
cabinets and overrides (see list below).
Item #8 Common Misconceptions about Electrosurgery
was discussed in detail in our July 28,
2020 Patient Safety Tip of the Week Electrosurgical Safety and our many columns on surgical fires and
iatrogenic burns.
Item #1 At-home medical devices
highlights the
problem of information about medical device recalls not reaching the end users.
It is timely in view of a recent proposal to allow medical devices to be
tracked on claims forms (Kadakia 2023).
Some of our prior columns on the hazards associated with
telemetry:
- June
19, 2007 Unintended Consequences
of Technological Solutions
- April
1, 2008 Pennsylvania PSAs FMEA
on Telemetry Alarm Interventions
- February
23, 2010 Alarm Issues in the
News Again
- July
2011 What's New in the
Patient Safety World
- February
4, 2014 But What If the Battery
Runs Low?
- May
22, 2018 Hazardous
Intrahospital Transport
- June
23, 2020 Telemetry Incidents
Our prior columns related to ADCs (automated dispensing
cabinets):
December 2007 1000-fold
Heparin Overdoses Back in the News Again
August 23, 2016 ISMP
Canada: Automation Bias and Automation Complacency
December 11, 2018 Another
NMBA Accident
January 1, 2019 More
on Automated Dispensing Cabinet (ADC) Safety
February 12, 2019 From
Tragedy to Travesty of Justice
April 2019 ISMP
on Designing Effective Warnings
June 11, 2019
ISMPs Grissinger
on Overreliance on Technology
September 7, 2021 The Vanderbilt Tragedy Gets
Uglier
References:
ECRI Institute. Top 10 Health Technology Hazards for 2023
Executive Brief. ECRI 2023
Kadakia K T, Dhruva S S, Ross J S, Krumholz H M. Adding
device identifiers to claims formsa key step to advance medical device safety BMJ
2023; 380 : p82
https://www.bmj.com/content/380/bmj.p82
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