What’s New in the Patient Safety World
January 2015
ECRI Institute’s Top 10 Technology Hazards for 2015
Each year ECRI Institute puts out its list of the top 10 health technology hazards. The ECRI Institute Top 10 Health Technology Hazards for 2015 list is now out:
- Alarm hazards: Inadequate alarm configuration policies and practices
- Data integrity: Incorrect or missing data in electronic health records and other health IT systems
- Mix-up of IV lines leading to misadministration of drugs and solutions
- Inadequate reprocessing of endoscopes and surgical instruments
- Ventilator disconnections not caught because of mis-set or missed alarms
- Patient-handling device use errors and device failures
- “Dose creep”: Unnoticed variations in diagnostic radiation exposures
- Robotic surgery: Complications due to insufficient training
- Cybersecurity: Insufficient protections for medical devices and systems
- Overwhelmed recall and safety alert management programs
As usual, ECRI Institute provides excellent recommendations at preventing or mitigating the impact of incidents related to each of these hazards.
Issues related to alarm management and information technology dominate the list. Leading the list again is alarm hazards and this should be no surprise. But alarm issues leading to ventilator disconnections got its own place on this year’s list. Robotic surgery and inadequate reprocessing of endoscopes and instruments are holdovers from last year. Issues related to patient-handling devices (lifts, transfer devices, etc.) may not sound particularly hi-tech but staff need education on the use and maintenance of all such devices. Similarly, the focus on IV’s this year is not so much on the hi-tech infusion devices but rather on making sense out of the tangle of IV lines linked to our sickest patients. Also new to this year’s list is hazards related to recall and safety alerts. We’re pleased to see that make the list. Our February 26, 2013 Patient Safety Tip of the Week “Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?” highlighted the problem of hospitals having inadequate systems to deal with such alerts or recalls.
We won’t steal ECRI’s thunder. Read the report yourself. The full report can be downloaded free at the ECRI Institute website. This is a very informative and useful document that you should make full use of.
References:
ECRI Institute. ECRI Institute Announces Top 10 Health Technology Hazards for 2015. Press Release November 25, 2014
report download site:
https://www.ecri.org/Pages/2015-Hazards.aspx
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