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ECRI Unveils Top 10 Health Technology Hazards

John Commins, for HealthLeaders Media, November 14, 2011

6. Enteral feeding misconnections

Misconnections usually take one of two forms: nutrients intended for the gastrointestinal tract are delivered elsewhere; and inappropriate fluids are delivered to the GI tract. The first problem is the more serious because it can result in death by embolism or sepsis, the report said.

ECRI recommends that enteral pumps be used for enteral feeding only, and that color-coded feeding lines and connectors be traced from end to end when making initial connections. The report also recommends that the standard Luer syringe never be used for oral medications or enteral feedings, and that IV or feeding devices never be adapted for other purposes. 

7. Surgical fires
ECRI said it continues to receive reports of one or two surgical fires each week, and the institute estimates that there are about 600 surgical fires each year nationally. "Not all surgical fires result in patient injury, but when they do, the consequences can be severe, including potentially fatal airway burns and horrible facial disfigurement," the report says.

"Virtually all surgical fires can be avoided. But doing so requires that each member of the surgical team clearly understands the role played by oxidizers, ignition sources, and fuels in the operating room." ECRI recommends that hospitals implement surgical fire prevention and management programs; that include familiarization with risks posed by oxygen-enriched air.

The report also recommends discontinuing the traditional practice of open delivery of 100% oxygen during head, face, neck, and upper chest surgery.

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