The ECRI Institute has unveiled its Top 10 Health Technology Hazards for 2018, which highlights what the Institute feels are the greatest potential sources of danger involving medical devices and other health technologies for the upcoming year.
To compose the list, ECRI Institute engineers, scientists, clinicians, and other patient safety analysts nominated topics for consideration and also considered the thousands of health-technology-related problem reports the Institute has received through its Problem Reporting Network and through data shared with our patient safety organization, ECRI Institute PSO. They also weighed factors like severity, likelihood that the hazard could cause serious injury or death, frequency, overall likelihood and the likelihood of the spread to affect a great number of people, either within one facility or across many facilities, insidiousness, and preventability among other factors.
1. Cybersecurity threats in healthcare delivery and patient endangerment
In the healthcare environment, ransomware and other types of malware attacks constitute potential patient safety crises that can put patients' lives in jeopardy by stalling or halting operations and care delivery. Disruptions can include compromising patient care with canceled procedures, workflow changes, closure of care units or information data breaches.
Endoscope reprocessing with an alcohol flush. Credit: YouTube
2. Endoscope reprocessing
Consistently and effectively cleaning, disinfecting, and sterilizing these instruments remains a challenge. These types of errors can lead to deadly infections in patients. ECRI Institute recommends healthcare facilities quality assurance processes for cleaning such as magnification-aided visual inspections and the use of biochemical testing as well as stronger methods of drying endoscope channels after reprocessing.
Cleaning a hospital bed. Credit: YouTube
3. Bed and stretcher mattress contamination
This can occur even after cleaning, creating the risk of exposure to body fluids or microbiological contaminants. Examples of reported incidents included patients on an apparently clean bed or stretcher when blood from a previous patient oozed out of the support surface onto the patient. Regular inspections of mattresses and covers are suggested to identify damage or contamination.
Connected medical device for nurses in the ICU. Credit: YouTube
4. Secondary alarm notification systems
These are software solutions that send alerts from a medical device or IT system to a clinician's smartphone or other communication devices. They are supposed to be a means for timely notification. Delayed or failed delivery of a critical alarm or alert can lead to missed alarm conditions, delayed care, and avoidable patient harm. Configuration and validation during installation of tech as well as regularly checking of system integrity during use can help minimize problems.
Cleaning machine for medical devices. Credit: YouTube
5. Medical device cleaning methods
Exposing medical devices and equipment to the wrong cleaning agents or cleaning methods has lead to deterioration of a device's nonmetallic parts, and ultimately undetected weakening, breakage or malfunctions. These and other consequences can trigger performance and safety issues, such as equipment failure, power supply interruptions, excessive and often incorrect alarms, or unexpected motion or device operation. Despite the challenge, hospitals should stock and use multiple cleaning products and educate staff on device-specific cleaning methods.
An electrosurgical pencil. Credit: YouTube
6. Electrosurgical electrode pencil handling
Failure to safely holster these devices in between activations or after done with entirely can lead to burns or fires if the ESU is inadvertently activated. It's something ECRI Institute has received reports of, investigated and published guidance on for years due to resulting burns, arcing, and fires due to inadvertent activation of ESU pencils. Consistent use of safety holsters for active-electrode pencils can prevent accidents.
MRI machine. Credit: YouTube
7. Digital imaging tools to control radiation
ECRI found these tools are often not used to their full advantage, opening up the possibility of high doses of ionizing radiation. Repeated exposures can increase a patient's long-term risk of getting and severely high doses can cause radiation burns. To reduce long-term risks, users need to be proficient in the use of tools to prevent unnecessary exposure.
8. Bar-coded medication system workarounds
Administering medications before using the bar-code scanner, scanning patient barcodes from a list of stickers on a clipboard instead of from the patient wristband, and preparing medications for more than one patient at a time cause a variety of problems. These behaviors can be fueled by such things as system configuration that does not support safe clinician workflow, lack of understanding or a system that is not user-friendly, reliable or well maintained. During implementation, train staff on the multi-step workflow and monitor the devices to ensure they function properly.
9. Networked medical devices and information systems
Errors in this area can delay treatment or cause a dangerous misdiagnosis. Some reported errors included lab results being delivered from a laboratory information system to the electronic health record with reference ranges but no lab values, leading to a delay in patient diagnosis and treatment. Regular monitoring of systems is needed along with a scheduled plan to assess, approve and implement changes.
ENFit tubing system. Credit: YouTube
10. Enteral feeding tubing erroneously connected to patient lines
ECRI said in one deadly incident, enteral nutrition was delivered into a patient's lungs when feeding tubing was improperly connected to a ventilator suction catheter. A new standards-based connector design for enteral feeding systems known by its trademarked name ENFit could help prevent these errors because the connectors fit only with each other, not with other connector types. A transition to 9 enteral devices with ENFit connectors is recommended by ECRI and other organizations to avoid these issues.