ECRI Institute has published its annual list of top 10 health technology hazards that can lead to accidents and patient harm. Heading the list of issues that need to be addressed in 2015 are alarm hazards, electronic health record data integrity problems, and infusion line mix-ups.
Issues with medical alarms are appearing on the list for the fourth year in a row. This year, the report draws particular attention to clinical alarm configuration practices. ECRI Institute reports that it is aware of several deaths and other cases of severe patient harm that may have been prevented with more effective alarm policies and practices.
Another hazard on the list is recall management, which points to overwhelmed recall and safety-alert programs as a potential for serious consequences for healthcare facilities and patients. ECRI experts reported a concern that existing hospital recall tracking programs are not keeping pace with the growing number of medical device recalls issued each year. ECRI cites the FDA as reporting that the annual number of medical device recalls nearly doubled between 2003 and 2012, from 604 recalls to 1,190 annually.
The full list follows:
- Alarm hazards: Inadequate alarm configuration policies and practices
- Data integrity: Incorrect or missing data in electronic health records and other health IT systems
- Mix-up of IV lines leading to misadministration of drugs and solutions
- Inadequate reprocessing of endoscopes and surgical instruments
- Ventilator disconnections not caught because of mis-set or missed alarms
- Patient-handling device use errors and device failures
- “Dose creep”: Unnoticed variations in diagnostic radiation exposures
- Robotic surgery: Complications due to insufficient training
- Cybersecurity: Insufficient protections for medical devices and systems
- Overwhelmed recall and safety alert management programs
For each topic in the report, ECRI describes the hazard, presents action steps to aid healthcare facilities in their efforts to maintain a safe environment for patients and healthcare workers, and lists helpful resources that readers can access to learn more about the topic.
The Top 10 Health Technology Hazards report is available for download on ECRI’s website (registration required).