4. Patient data mismatches in electronic health records and other health IT systems.
EHR mismatched data errors don't necessarily happen because of carelessness or user error, but could result from design flaws or software anomalies. "If the problem is one that is not easily discoverable, many patients could be affected before the defect is found," the report says.
Precautions should be taken to avoid errors resulting from network outages. For example, a system may continue recording information from a patient monitoring device during the outage, but if the device is moved from one patient to another, "the stored information could be sent to the wrong patient's record once the network comes back online."
5. Interoperability failures with medical devices and heath information technology systems.
The report notes a surprisingly frequent problem in which interfaces between medical devices do not work. "When testing connectivity between physiologic monitoring systems and ventilators, we found that most of the interfaces we tested did not function as desired—and some even allowed dangerous conditions to exist."
"For example, one monitoring system did not communicate audible or visual alarms from an interfaced ventilator to warn caregivers of a critical patient circuit disconnection, a condition that would result in the patient no longer receiving respiratory support."
6. Air embolism hazards.
Appearing on the ECRI hazards list for the first time, the problem of air embolisms may be increasing with potentially fatal consequences because of the expanding types of technology that may create opportunities for them to occur.
For example, the report says, automatic contrast media injectors for radiologic procedures, central venous access devices, and pressurized spray devices for applying fibrin sealants for blood clotting may result in the need to resuscitate patients.
7. Inattention to the needs of pediatric patients when using "adult" technologies.
When adult technologies are used on children without appropriate modifications or dosage reductions harm may occur. Radiology is one example, where an adult dose of radiation, or overuse of imaging scans, may cause cancer in a child.