From radiation overdose to tubing misconnections, find out which technologies were deemed most dangerous for 2010, and what can be done to prevent incidents.
Although medical technologies and health care IT offer countless advantages in improving the quality of care, there are also pitfalls that providers must be aware of. In a new report, the ECRI Institute, an independent group that evaluates medical devices and procedures, has identified the 10 most dangerous technologies in health care for 2011.
The aim of the report is “to increase awareness of these hazards and to stimulate action within healthcare facilities to formulate programs that succeed in minimizing the dangers.” With this resource, leaders in hospital administration, clinical departments, and clinical engineering will be able to more effectively prioritize their patient safety efforts, according to ECRI.
The top 10 hazards are as follows:
1. Radiation Overdose and Other Dose Errors during Radiation Therapy
The authors of the report advise hospitals to make sure all staff members have up-to-date and appropriate certifications and training and that staffing levels are adequate. It is critical that systems are maintained to ensure that patient treatment procedures are documented and followed, with attention to providing oversight of incident reporting and safety alerts management.
2. Alarm Hazards
Clinical alarm problems once again made the news this past year when the Boston Globe reported “the death of a patient whose treatment may have been delayed because of a critical physiologic monitoring alarm had been turned off," the authors wrote, citing the dangers of alarm fatigue.
3. Cross Contamination from Flexible Endoscopes
"At minimum, endoscope reprocessing problems, when discovered, can inconvenience patients and create anxiety; at worst, they can lead to life-threatening infections," the report stated. With the scheduled removal of the Steris System 1 sterilizing units, hospitals will be purchasing new units, changing protocols, and maybe buying new endoscope models. The authors advise providers to review protocols, staff training and maintenance schedules.
4. The High Radiation Dose of CT Scans
A 2009 study suggested that 29,000 cases of cancer may have been caused by radiation doses administered during CT imaging scans in 2007 alone, according to the report. “While the increased risk of cancer cannot be reliably quantified, it clearly is a risk that healthcare facilities must take steps to mitigate," it said. “A delicate balance must be achieved between keeping doses low and maintaining adequate image quality."
5. Data Loss, System Incompatibilities and Other Health IT Complications.
The convergence of medical technology and health IT can present risks if data is lost, overwritten, unsuccessfully transmitted, or associated with the wrong patient, said the report. With HIT increasing dramatically, "it is vital that healthcare organizations take steps now to keep HIT problems from exploding at their facilities.”
6. Tubing Misconnections
Tubing and catheter misconnections can result in gases or liquids to be introduced into the wrong lines, according to the report. Between January, 2008 and September 2009, 36 reports of tubing miscommunication were reported in Pennsylvania alone, with incidents ranging from near misses to serious events.
7. Oversedation During Use of PCA Infusion Pumps
Patient-controlled analgesic (PCA) infusion pumps were cited "because of the particular dangers associated with delivering opioids" through this mechanism, usually used to deliver high-alert medications. "The most significant danger when using PCA pumps is oversedation, which can lead to potentially life-threatening narcotic-induced respiratory depression," the authors wrote.
8. Needlesticks and Other Sharps Injuries
The number of injuries "remains staggering, despite the implementation of safety devices and the emphasis on training over the past 15 to 20 years,” according to the authors, who said prevention programs in these settings may be outdated. The ECRI advices health care facilities to routinely review and refine their sharps safety efforts, making sure that all personnel are properly trained.
9. Surgical Fires
An estimated 600 surgical fires occur each year, said the ECRI, which has developed clinical practice recommendations for delivering oxygen during surgery, in conjunction with the Anesthesia Patient Safety Foundation. Staff should be made aware of fire hazards from oxidizers, ignition sources, and operating room fuels
10. Defibrillator Failures in Emergency Resuscitation Attempts
According to the FDA, there have been “many reports of incidents in which defibrillators didn't discharge during resuscitation attempts for various preventable reasons, (such as depleted batteries).” To guard against these mishaps, clinicians responsible for using defibrillators should perform recommended checks "at least daily" and ensure that the unit is plugged in and batteries are charging.
Will the information provided in this report help your organization to more effectively prioritize patient safety efforts? Do you think enough is being done to ensure that health technologies are safe?