Social media has created a storm of Top 10 lists – Top 10 Bizarre ICD-10 Codes, Top 10 Dumbest Patients – these are only a couple of the click bait links waiting online. What is not as entertaining is the Top 10 Health Technology Hazards for 2016 list ECRI Institute released. Most of them link directly to the operating room, but all 10 could impact surgical patients. They include:
- Inadequate cleaning of flexible endoscopes before disinfection can spread deadly pathogens
- Missed alarms can have fatal consequences
- Failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death
- Inadequate surveillance of monitored patients in a telemetry setting may put patients at risk
- Insufficient training of clinicians on operating room technologies puts patients at increased risk of harm
- Errors arise when HIT configurations and facility workflow do not support each other
- Unsafe injection practices expose patients to infectious agents
- Gamma camera mechanical failures can lead to serious injury or death
- Failure to appropriately operate intensive care ventilators can result in preventable ventilator-induced lung injuries
- Misuse of USB ports can cause medical devices to malfunction
The No. 1 health hazard was inadequately cleaned flexible endoscopes. Without being cleaned properly before sterilization, bacteria can still fester and infect patients. Recent lawsuits and splashy headlines make this one predictable, but there does not seem to be a clear solution. All experts can suggest is to follow manufacturer guidelines and implement an enhanced practice, such as using:
- Ethylene oxide sterilization after high level disinfection with periodic microbiologic surveillance
- Double high-level disinfection with periodic microbiologic surveillance
- High-level disinfection with scope quarantine until negative culture
- Liquid chemical sterilant processing system using peracetic acid with periodic microbiologic surveillance
- High-level disinfection with periodic microbiologic surveillance
Some of the other hazards listed have solutions. The No. 2 hazard was missing alarms on medical devices or ignoring the alarms when they went off. Responding to these in a timely manner and making sure all staff understand the alarms could help solve this issue.
The No. 3 hazard was failing “to monitor postoperative patients for opioid-induced respiratory depression.” This complication, which can lead to brain injury or death, can happen to patients with undiagnosed comorbidities or otherwise healthy patients on another sedative. ECRI Institute directs facilities to the Anesthesia Patient Safety Foundation (APSF) and the Joint Commission recommendations.
No. 10 surprised me. With all the technology in healthcare, I did not realize plugging in an unauthorized USB port could cause a medical device to shut down and result in setting reconfiguration, let alone jeopardise patient information and the system’s security. While it makes sense, I can see why these serious errors happen.
Most of these hazards come down to training and constant vigilance. Of course, during a long shift at a demanding job, this is easier said than done.
What do you think of this top 10 list? Do you think anything was missed? Comment below or reach out to me at Rebecca.Rudolph@AdvantageMedia.com.