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ECRI Unveils Top 10 Health Technology Hazards

John Commins, for HealthLeaders Media, November 14, 2011

3. Medication administration errors using infusion pumps.

While infusion pump technology has improved over the years with the introduction of "smart" pumps, preventable errors continue to occur, and the entire infusion process should be examined, the report says.

Typical problems include illegible orders, incorrectly prepared drugs and solutions, and medication given to the wrong patient. ECRI recommends that providers consider infusion pumps as part of the overall medication delivery system, and determine the compatibility with other safety systems already in place.

Providers should develop drug libraries for clinical areas that use infusion pumps to create standardized concentrations of commonly used drugs and solutions, ECRI recommends.

4. Cross-contamination from flexible endoscopes

The report notes that when endoscope reprocessing problems surface, they can create great anxiety among patients who are told that they may have been exposed, and they can be highly damaging to a healthcare facility's reputation. "At worst, they can lead to life-threatening infections. Such incidents are almost always associated either with failure to follow established cleaning and disinfection/sterilization guidelines and instructions, or with the use of damaged or malfunctioning equipment," the report says.

"Flexible endoscope reprocessing requires consistent adherence to a multi-step procedure. Failure to properly perform any step, including some necessary manual tasks, could compromise the integrity of the process."

ECRI recommends that healthcare facilities; have strict and detailed reprocessing protocols for every model of flexible endoscope in their inventory; periodically review those protocols; and make sure the protocols are readily available to employees who are responsible for the reprocessing.

5. Inattention to change management for medical device connectivity

Problems are arising with the growing interrelationship between medical technology and IT, and the potential for incompatibility. "A key reason problems arise is the failure to implement adequate change management policies and procedures that accommodate both IT and medical technology needs," the report says.

"Because medical devices and health IT are becoming so interconnected, healthcare facilities must be aware of a possible domino effect wherein changes to one component of the system affect the operation of another." ECRI recommends that healthcare facilities evaluate policies and procedures around change management to ensure that issues around healthcare IT and convergence are addressed, with particular care taken to determine how technology decisions involving medical devises and IT networks can impact operations and patient care.

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