Every year hospitals are blindsided and patients are harmed by unexpected health technology hazards. Medical technology is intended to improve patient care, but even the best of technology—if configured, used, or maintained improperly—can lead to problems. “With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked,” says Anthony Montagnolo, chief operating officer, ECRI Institute. “Based on our experience with independent medical device testing in our laboratory, accident investigations, and reported events, we’re very aware of serious safety problems that occur.”
To help hospitals prioritize technology safety efforts that warrant their attention and to reduce risks to patients, ECRI Institute publishes an annual list of top 10 health technology hazards.
A series of fatal Carbapenem-resistant Enterobacteriaceae (CRE) infections that attracted national media attention in 2014 and 2015—combined with ECRI Institute’s own studies into endoscope cleaning and disinfection practices—prompted ECRI safety engineers to elevate flexible endoscope reprocessing to the top of the 2016 list. This year’s top hazard specifically addresses the need to adequately clean flexible endoscopes before disinfection to help prevent the spread of deadly pathogens.
Safety risks from clinical alarms, a perennial No. 1 hazard, moved down to the No. 2 spot. Failure to recognize and respond to actionable clinical alarm conditions in a timely manner can result in serious patient injury or death, according to ECRI’s report. It remains an important issue for hospitals as non-compliance with the Joint Commission’s January 1, 2016, deadline for its National Patient Safety Goal on clinical alarms can put patients at risk of harm.
Other topics on the 2016 list include failure to effectively monitor post-op patients for opioid-induced respiratory depression, inadequate surveillance of telemetry-monitored patients, insufficient physician training on new OR technologies, health IT errors, gamma camera mechanical failures, and more.