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ECRI Announces Top 10 Healthcare Technology Hazards

Cheryl Clark, for HealthLeaders Media, November 5, 2013

Health technologies seen as likely to cause patient harm in 2014 are:

1. Alarm hazards
Device alarms have "doubtless saved many lives," the report says, but have overwhelmed, or distracted, or desensitized caregivers to their importance, so real alerts go unattended. In April, a sentinel alert from The Joint Commission noted 98 harm-related events, 80 of which resulted in death, and 13 resulting in permanent loss of patient function.

This hazard has been in each of ECRI's seven annual hazards lists and doesn't appear to be a problem that providers are able to solve.

"A big factor is the growth in number of devices with alarms," Keller says. "It's created a growing complexity that caregivers have to manage."

2. Infusion pump medication errors
Hospitals may have thousands of these pumps, whose misuse or failure produce more adverse incident reports to the FDA than any other medical technology. Because some patients are highly sensitive to fluids and drugs they receive through these pumps, wrong dosages can be lethal. Some 710 deaths were reported to the FDA between 2005 and 2009.

ECRI says that since the FDA's regulatory action against Baxter and Hospira pumps last year have prompted healthcare facilities "to switch to unfamiliar brands."

The report says "some pumps have buttons that are not labeled in an intuitive manner" or "involve user interfaces that are cumbersome to navigate. In a sample of events reported to ECRI's PSO, 29% involved wrong concentrations of drugs, 19% the wrong entry of more than one parameter, and 15% involved a piggyback infusion setup error.

3. CT radiation exposures in pediatric patients
While CT radiation overdoses made the previous four annual reports, this year's caution is issued specifically for CT in children because of concerns that ionizing radiation can be especially risky to growing human tissue.

The report's authors issue cautions about use of adult doses of radiation for children, and use of lower-radiation alternatives such as MRI, ultrasound, and X-rays, and avoiding repeat scans by checking on whether a CT has been done recently at another institution.

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