What’s New in the Patient Safety World

November 2018

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:

 

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:

1.     Hackers Can Exploit Remote Access to Systems, Disrupting Healthcare Operations

2.     “Clean” Mattresses Can Ooze Body Fluids onto Patients

3.     Retained Sponges Persist as a Surgical Complication Despite Manual Counts

4.     Improperly Set Ventilator Alarms Put Patients at Risk for Hypoxic Brain Injury or Death

5.     Mishandling Flexible Endoscopes after Disinfection Can Lead to Patient Infections

6.     Confusing Dose Rate with Flow Rate Can Lead to Infusion Pump Medication Errors

7.     Improper Customization of Physiologic Monitor Alarm Settings May Result in Missed Alarms

8.     Injury Risk from Overhead Patient Lift Systems

9.     Cleaning Fluid Seeping into Electrical Components Can Lead to Equipment Damage and Fires

10.  Flawed 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:

 

 

 

References:

 

 

ECRI Institute. 2019 Top 10 Health Technology Hazards. ECRI 2018

https://www.ecri.org/Pages/Top-Ten-Tech-Hazards.aspx

 

 

 

 

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