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TOP 10 HEALTH TECHNOLOGY HAZARDS FOR 2013
Reprinted from Volume 41 Issue 11 November 2012
guidance
ARTICLE
TOP 10 HEALTH TECHNOLOGY HAZARDS FOR 2013
EACH YEAR, ADVANCES IN HEALTH TECHNOLOGIES PROVIDE NEW WAYS TO IMPROVE PATIENT CARE. BUT SOME ALSO CREATE NEW OPPORTUNITIES FOR HARM. THUS, HOSPITALS MUST REGULARLY EXAMINE THEIR HAZARD-CONTROL PRIORITIES IN ORDER TO REMAIN FOCUSED ON THEMOST PRESSING RISKS. OUR ANNUAL LIST WILL HELP YOU MAKE SMART DECISIONS ABOUT YOUR SAFETY INITIATIVES IN THE COMING YEAR.
THE LIST FOR 2013
1. Alarm hazards 2. Medication administration errors using infusion pumps 3. Unnecessary exposures and radiation burns from diagnostic radiology procedures 4. Patient/data mismatches in EHRs and other health IT systems 5. Interoperability failures withmedical devices and health IT systems 6. Air embolism hazards 7. Inattention to the needs of pediatric patients when using “adult” technologies 8. Inadequate reprocessing of endoscopic devices and surgical instruments 9. Caregiver distractions from smartphones and other mobile devices 10. Surgical fires
Ensuring the safe use of health technology requires identifying possible sources of danger ordifficulty involving medical devices and systems—our definition of the term “hazards”—and taking steps to minimize the likelihood that adverse events will occur. With the vast array of technologies in use at a modern healthcare facility, however, deciding where to commit limited resources is a continual challenge. Our annual Top 10 list highlights the technology safety topics that we believe warrantparticular attention for the coming year. Some are hazards that we see occurring with regularity. Some are problems that we believe will become more prevalent, given the way the technology landscape is evolving. And some are well-known topics that periodically warrant renewed attention because of their potential to cause harm. The list is not comprehensive, nor will all of the hazards listed herebe applicable at all healthcare facilities. We encourage facilities to use the list as a starting point for patient safety discussions and for setting their health technology safety priorities.
1
www.ecri.org/2013hazards ©2012 ECRI Institute. ECRI Institute encourages the dissemination of the registration hyperlink to access a download of this report, but prohibits the direct dissemination,posting, or republishing of this work, without prior written permission.
Key Patient Safety Risks, and How to Keep Them in Check
Why a Top 10 List?
“Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”* That quote from the head of an academic health science system captures the essence of why a list like this one isneeded. The technologies and procedures we describe in this list all can contribute to effective patient care. However, most are also complex or their effective application relies on a complex interplay of factors. Thus, they can actually cause harm—to patients, staff, or others—if, for example, design flaws are not identified and rectified, equipment is not adequately maintained or otherwise prepared foruse, or proper use procedures are not established and followed (e.g., to address risks that are inherent to the technology). ECRI Institute routinely addresses model-specific design, use, and maintenance issues through our technology evaluation, problem reporting, accident investigation, and alerting services. For this
* Chantler C. The role and education of doctors in the delivery of healthcare.Lancet 1999 Apr 3;353(9159):1178-81.
Top 10 list, we focus only on what we call generic hazards—problems that result from the risks inherent to the use of certain types or combinations of medical technologies. The hazards we discuss here reflect use errors that our research shows are being repeated by clinicians or that our experts determine may become more prevalent (e.g., as a technology...
Reprinted from Volume 41 Issue 11 November 2012
guidance
ARTICLE
TOP 10 HEALTH TECHNOLOGY HAZARDS FOR 2013
EACH YEAR, ADVANCES IN HEALTH TECHNOLOGIES PROVIDE NEW WAYS TO IMPROVE PATIENT CARE. BUT SOME ALSO CREATE NEW OPPORTUNITIES FOR HARM. THUS, HOSPITALS MUST REGULARLY EXAMINE THEIR HAZARD-CONTROL PRIORITIES IN ORDER TO REMAIN FOCUSED ON THEMOST PRESSING RISKS. OUR ANNUAL LIST WILL HELP YOU MAKE SMART DECISIONS ABOUT YOUR SAFETY INITIATIVES IN THE COMING YEAR.
THE LIST FOR 2013
1. Alarm hazards 2. Medication administration errors using infusion pumps 3. Unnecessary exposures and radiation burns from diagnostic radiology procedures 4. Patient/data mismatches in EHRs and other health IT systems 5. Interoperability failures withmedical devices and health IT systems 6. Air embolism hazards 7. Inattention to the needs of pediatric patients when using “adult” technologies 8. Inadequate reprocessing of endoscopic devices and surgical instruments 9. Caregiver distractions from smartphones and other mobile devices 10. Surgical fires
Ensuring the safe use of health technology requires identifying possible sources of danger ordifficulty involving medical devices and systems—our definition of the term “hazards”—and taking steps to minimize the likelihood that adverse events will occur. With the vast array of technologies in use at a modern healthcare facility, however, deciding where to commit limited resources is a continual challenge. Our annual Top 10 list highlights the technology safety topics that we believe warrantparticular attention for the coming year. Some are hazards that we see occurring with regularity. Some are problems that we believe will become more prevalent, given the way the technology landscape is evolving. And some are well-known topics that periodically warrant renewed attention because of their potential to cause harm. The list is not comprehensive, nor will all of the hazards listed herebe applicable at all healthcare facilities. We encourage facilities to use the list as a starting point for patient safety discussions and for setting their health technology safety priorities.
1
www.ecri.org/2013hazards ©2012 ECRI Institute. ECRI Institute encourages the dissemination of the registration hyperlink to access a download of this report, but prohibits the direct dissemination,posting, or republishing of this work, without prior written permission.
Key Patient Safety Risks, and How to Keep Them in Check
Why a Top 10 List?
“Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”* That quote from the head of an academic health science system captures the essence of why a list like this one isneeded. The technologies and procedures we describe in this list all can contribute to effective patient care. However, most are also complex or their effective application relies on a complex interplay of factors. Thus, they can actually cause harm—to patients, staff, or others—if, for example, design flaws are not identified and rectified, equipment is not adequately maintained or otherwise prepared foruse, or proper use procedures are not established and followed (e.g., to address risks that are inherent to the technology). ECRI Institute routinely addresses model-specific design, use, and maintenance issues through our technology evaluation, problem reporting, accident investigation, and alerting services. For this
* Chantler C. The role and education of doctors in the delivery of healthcare.Lancet 1999 Apr 3;353(9159):1178-81.
Top 10 list, we focus only on what we call generic hazards—problems that result from the risks inherent to the use of certain types or combinations of medical technologies. The hazards we discuss here reflect use errors that our research shows are being repeated by clinicians or that our experts determine may become more prevalent (e.g., as a technology...
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