Infusion errors represent the top hazard compromising safe use of medical technology, according to the Top 10 Health Technology Hazards for 2017 report, recently released by ECRI Institute. Produced each year by ECRI Institute’s Health Devices Group, the list identifies the potential sources of danger that ECRI believes warrant the greatest attention for the coming year. The guidance that accompanies the list provides practical strategies for reducing the risks.
“Technology safety can often be overlooked when hospital leaders are dealing with so many other issues,” says David T. Jamison, executive director, health devices group, ECRI Institute. “As an independent medical device testing laboratory and investigator of technology-related incidents, we know what can go wrong and what steps hospitals can take to reduce patient harm related to specific technologies and processes.”
According to the report, infusion errors can still occur when using large-volume infusion pumps. Although today’s pumps incorporate features that reduce the risks of infusion errors, these safety mechanisms cannot eliminate all potential errors, and the mechanisms themselves have been known to fail. ECRI Institute continues to receive reports and investigate incidents of uncontrolled flow of medication to the patient—a potentially fatal circumstance known as “IV free flow”—and other infusion errors. Fortunately, as ECRI points out in its guidance document, a few simple steps can help catch use errors and component failures before patient care is affected.
Inadequate cleaning of complex reusable instruments, including duodenoscopes, remains high on the list this year in the No. 2 spot due, in part, to the severity of the infection risks and also the persistence of the problem: ECRI Institute regularly sees reports of contaminated medical instruments being presented for use on a patient.
Other topics on the 2017 list include ventilator alarm management, infection risks with heater-cooler devices, undetected opioid-induced respiratory depression, software management oversights, occupational radiation hazards in hybrid ORs, and more.
To develop the annual list, ECRI Institute’s multidisciplinary staff of engineers, scientists, nurses, physicians, and safety analysts draw on the resources of the Institute’s nearly 50-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. Topics on the list are selected by weighing factors such as the severity, frequency, breadth, insidiousness, and profile of the hazard. Additionally, all the hazards selected can, at least to some degree, be prevented by implementing appropriate measures.
The Top 10 Health Technology Hazards for 2017 Executive Brief is available for free download at www.ecri.org/2017hazards.