The ECRI Institute, an independent nonprofit company that evaluates medical devices and processes, has published its list of the 10 most dangerous technological hazards in healthcare.
The organization made its choice and prioritized the order "based on the likelihood and severity of the reports we've received over the past year, the recalls and other actions we've reviewed, and our continuing examination of the published literature," ECRI authors wrote in their introduction.
These 10 are "problems that we believe are the most crucial right now, and that hospitals should consider putting at the top of their to-do lists for keeping patients safe from technology-related risks."
1. Cross-contamination from flexible endoscopes. "Often in these cases, large numbers of patients must be notified of exposure to potentially contaminated endoscopic equipment."
The incidents are "almost always associated" with failure to follow sterilization guidelines or with malfunctioning equipment.
2. Alarm hazards. Alarms warn when a patient is at risk of injury or death because of an instrument malfunction. But "alarm issues are among the problems most frequently reported to ECRI Institute. The variety of affected equipment is considerable —reports involve patient monitoring equipment, ventilators, dialysis units, and many other devices."
The report suggests facilities look for alarm designs that limit false or excessive alarming, which can prompt caregivers to ignore true hazards. "We continue to learn of incidents in which staff unintentionally disable critical alarms by setting them far outside reasonable bounds. Low-saturation alarms on pulse oximetry monitors and low-minute volume or high-peak-volume alarms on ventilators are regular subjects of this sort of error."
3. Surgical fires. Each year, 550 to 650 surgical fires occur in the U.S., caused mostly by the combination of oxygen-rich atmosphere in or near the surgical site. New recommendations developed by ECRI with the Anesthesia Patient Safety Foundation suggest "open delivery of 100% oxygen should be discontinued during head, face, neck, and upper chest surgery."
4. CT radiation dose. With increasing use, doses "can pose significant cancer risk: In the United States alone, CT is thought to be responsible for about 6,000 additional cancers a year, roughly half of them fatal," the report said. According to the New England Journal of Medicine in August, "many CT studies expose patients to an unnecessary risk of cancer without a demonstrated benefit."
In one recent highly publicized case, brain perfusion CT scans at Cedars-Sinai Medical Center in California exposed 260 patients to radiation doses eight times normal. The ECRI report's authors believe "the focus on these hazards will only increase."
They advise facilities to make sure benefits of CT outweigh risks, minimize scanning protocols, make sure the scan has not already been done, and make sure technologists who perform the scans are specifically trained to do them and are registered with the American Registry of Radiologic Technologists.
5. Retained devices and unretrieved fragments. Devices all too frequently are left unknowingly inside patients after surgery. Device fragments, such as the tips of catheters or jaws of forceps, break away and remain inside patients, unbeknownst to the clinicians.
ECRI recommends visual inspection of devices prior to use and as soon as they are removed and suggests staff remain alert for significant resistance during removal.
6. Needlesticks and related injuries. "Accidental needlesticks and other sharps-related injuries keep happening," the authors wrote. To prevent these injuries, ensure that staff are trained and caution against making assumptions that a sharp is shielded just because the safety mechanism appears activated.
7. Problems with computerized equipment and systems. Convergence of medical and information technology can improve patient care. But "if systems and interfaces are poorly planned, implemented, or managed, they can threaten patient safety and can lead to inefficiencies, significant interruptions in operations, and uncaptured or lost revenue."
These technologies also carry a risk that patient images or data may be incorrectly transferred or processed, with the result being inaccurate matching of the patient to his or her data. According to the Joint Commission's report in December 2008, 25% of 176,409 medication errors in 2006 involved some aspect of computer technology.
8. Surgical stapler hazards. These staplers sometimes fail, resulting in prolonged surgery, serious tissue injury, and even death.
Some common problems include failure to position the stapler jaws on the tissue to be stapled, improper matching of stapler cartridge size to tissue thickness, and uneven distribution of the tissue in the stapler's jaws.
9. Ferromagnetic objects in the MR environment. Objects that can become magnetized in the presence of a magnetic field, such as that from an MRI machine, can turn wheelchairs, gas cylinders, and other objects into dangerous flying projectiles "hurtling with great force into the bore of the magnet." Additionally, implanted magnetic devices, such as aneurysm clips, can dangerously migrate because of the magnetic pull. Patients can be burned when currents are induced in electrically conductive materials.
The ECRI reported a Pennsylvania case in 2008 in which "there were 148 reports of problems related to inadequate screening that resulted in patients with implanted devices entering, or nearly entering, the MR scanner room."
As a precaution, providers should consider installing detectors to screen patients and equipment, update checklists and do not allow equipment into the MR room unless it has been determined to be safe.
10. Fiberoptic light-source burns. "Each year, ECRI Institute receives reports of burns to staff and patients resulting from use of these devices," according to the report. The two burn hazards most commonly reported are: Burns from light itself and burns from heated cable connections.