What’s New in the Patient Safety World

January 2011


ECRI’s Top 10 Health Technology Hazards for 2011



ECRI  Institute has published its annual list of its Top 10 Health Technology Hazards for 2011. The reprint can be downloaded for free from the ECRI site but you must register for that download. We won’t tell you all the items in the ECRI top 10 – you need to download the reprint and read it. But you won’t be sorry. They detail the risks of each of the technologies and make very useful recommendations on what your organization should be doing to minimize those risks.


Number one on their list is radiation therapy hazards. Note that we have previously discussed hazards of radiation therapy on several occasions (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation” and our March 2010 What’s New in the Patient Safety World column “More on Radiation Safety”). Also note that the New York Times has just done another article on errors related to radiation therapy, specifically stereotactic radiosurgery delivered via linear accelerators. This is another extremely disconcerting story about how an industry largely avoids oversight and regulation, where pieces of equipment are mixed or retrofitted to save costs, and training and quality control leave a lot to be desired. The scariest feature is that the only body collecting information on the scores of errors occurring with these devices is the New York Times!!! The ECRI paper has very useful recommendations on the training and competencies of staff specific to the devices and equipment being used, proper use of testing and monitoring, validation of treatment plans, and many others.


Number 4 on the ECRI list is the high radiation dose of CT scans. In our own two columns we mentioned above we discussed not only the risk of radiation exposure from single studies but also the cumulative radiation exposure risk and the fact that currently no one is tracking that for our patients – not we as physicians, not health systems, and not the patients themselves. We expounded on this in our November 23, 2010 Patient Safety Tip of the Week “Focus on Cumulative Radiation Exposure”. The ECRI paper has recommendations for monitoring radiation levels used in routine CT scanning and optimizing protocols.


Number 7 on the ECRI list is oversedation during use of PCA infusion pumps. Our May 12, 2009 Patient Safety Tip of the Week “Errors With PCA Pumps” dealt with a number of errors that may occur during use of patient controlled analgesia (PCA) and our April 27, 2010 Patient Safety Tip of the Week “Infusion Pump Safety” dealt with infusion pump issues in general. And we’ve discussed the issue of postoperative respiratory depression due to opioids in our Patient Safety Tips of the Week for July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression” and September 21, 2010 “Dilaudid Dangers”. The ECRI paper notes that the true prevalence of respiratory depression in patients on PCA is much higher than previously suspected since better monitoring has been implemented and may be as high as 41%. The ECRI recommendations are for monitoring not just vital signs but also mental status, pulse oximetry and capnography. They also discuss how to correctly assess the patients, use double checks for both orders and pump programming, and consider alternatives to PCA. In our multiple prior articles we have discussed identification of high-risk patients, correct use of sedation scales, and the dangers of oxygen in patients at risk for hypercapnia. We’ll be doing some updates on PCA pump issues in the near future as well.


No more hints on ECRI’s top 10! Download the reprint for yourselves As usual, ECRI’s evaluations are always thorough with very useful recommendations.






ECRI. ECRI Institute’s 2011 Top 10 Health Technology Hazards. Health Devices 2010; 39(11): 386-398




Bogdanich W, Rebelo K. A Pinpoint Beam Strays Invisibly, Harming Instead of Healing.

NY Times December 28, 2010
















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