What’s New in the
Patient Safety World
ECRI’s Top 10
Health Technology Hazards for 2019
ECRI Institute has released its Top 10 list for Health
Technology Hazards for 2019 (ECRI 2018).
Number 1 on the list is the threat of hackers and cybersecurity attacks.
Not surprisingly, two of the Top 10 items pertain to alarm
issues. One deals with cases of brain damage or death due to ventilator
breathing circuit disconnections during which no alarm activated because alarms
were not set appropriately. The other deals with alarm customization that can
create opportunities for missed alarms, and thus patient harm, when not handled
properly. See our list of our prior columns on alarm-related issues below.
Some old “staples”, such as retained surgical sponges and
problems with contaminated endoscopes, remain on the List.
We’re pleased to see that flawed battery charging systems
and practices made the list. That was the topic of our February 4, 2014 Patient Safety Tip of the Week “But
What If the Battery Runs Low?”. In that column we provided many
examples of battery-related problems that caused patient harm. We stressed that
every hospital should have an organized centralized program for battery
maintenance and do a full inventory of all your systems that utilize batteries.
The sorts of questions you should be asking are:
- What items use batteries?
- What would be the patient
(or facility) risk if the battery failed?
- What type of battery does
this equipment use?
- How do you know how much
battery life is left?
- Is there a way the battery
warns when charge is low?
Is it audible? Is it visible?
- Who checks the status of
- How often do they check
- Are there recommended replacement
- Is the battery
- If so, is there a memory?
(could the battery life diminish with frequent charging?)
- How are various devices
recharged on the units where they are used?
- Is the correct charger used
with this battery? (use of the wrong charger can result in undercharging)
- If the device this battery
is in loses all power does it reset to prior settings or to default
settings when power is restored?
- Who keeps track of all our
- Are there battery-related
issues in any of our root cause analyses (RCA’s) or incident
- How is our staff educated
on use of this device and battery issues?
- Do we survey end-users or
check service log issues before we reorder batteries for this device?
- Does your “Ticket to Ride”
patient transport communication tool have an item for discussion of
battery life issues on any transported devices?
- Do you include looking at
battery charging/recharging issues when you do your Patient Safety Walk Rounds?
And if you are using cell phones or pagers for alerting
staff to various alarms, consider doing a FMEA (failure mode and effects
analysis) and ask not only what would happen if the primary responder’s battery
is low but also what would happen if more than one responder’s battery is low.
We also note that
battery issues are one of the items you might pay attention to when doing Patient Safety Walk Rounds (see
our February 27, 2018 Patient Safety Tip of the Week “Update
on Patient Safety Walk Rounds”).
The full ECRI Top 10 List for 2019:
Hackers Can Exploit Remote Access to Systems,
Disrupting Healthcare Operations
“Clean” Mattresses Can Ooze Body Fluids onto Patients
Retained Sponges Persist as a Surgical Complication
Despite Manual Counts
Improperly Set Ventilator Alarms Put Patients at Risk
for Hypoxic Brain Injury or Death
Mishandling Flexible Endoscopes after Disinfection Can
Lead to Patient Infections
Confusing Dose Rate with Flow Rate Can Lead to Infusion
Pump Medication Errors
Improper Customization of Physiologic Monitor Alarm
Settings May Result in Missed Alarms
Injury Risk from Overhead Patient Lift Systems
Cleaning Fluid Seeping into Electrical Components Can
Lead to Equipment Damage and Fires
Battery Charging Systems and Practices Can Affect Device Operation
We hope you’ll go to the ECRI site to read all their comments
and recommendations on each of the items in their Top 10 List.
Prior Patient Safety
Tips of the Week pertaining to alarm-related issues:
5, 2007 “Disabled
26, 2007 “Alarms
Should Point to the Problem”
2, 2007 “More
19, 2007 “Unintended
Consequences of Technological Solutons”
1, 2008 “Pennsylvania
PSA’s FMEA on Telemetry Alarm Interventions”
23, 2010 “Alarm
Issues in the News Again”
2, 2010 “Alarm
Sensitivity: Early Detection vs. Alarm Fatigue”
- March 16, 2010 “A
Patient Safety Scavenger Hunt”
in the Operating Room”
- February 22, 2011 “Rethinking
- February 2013 “Joint
Commission Proposes New 2014 National Patient Safety Goal”
- May 2013 “Joint
Commission Sentinel Event Alert: Alarm Safety”
- July 2, 2013 “Issues
in Alarm Management”
- August 2013 “Joint
Commission Formalizes 2014 NPSG on Alarm Management”
- February 4, 2014 “But
What If the Battery Runs Low?”
- October 2014 “Alarm
Fatigue: Reducing Unnecessary Telemetry Monitoring”
- December 15, 2015 “Vital
Sign Monitoring at Night”
- February 9, 2016 “It
was just a matter of time…”
- August 16, 2016 “How
Is Your Alarm Management Initiative Going?”
- February 21, 2017 “Alarm
Fatigue in the ED”
- April 18, 2017 “Alarm
Response and Nurse Shift Duration”
- April 25, 2017 “Dialysis
and Alarm Fatigue”
- October 17, 2017 “Progress
on Alarm Management”
- November 21, 2017 “OSA,
Oxygen, and Alarm Fatigue”
- May 1 2018 “Refrigerator
ECRI Institute. 2019 Top 10 Health Technology Hazards. ECRI
Tip of the
What’s New in
the Patient Safety World Archive