Feature | November 20, 2013

ECRI Institute Releases Top 10 Health Technology Hazards Report for 2014

Alarm hazards, robotic surgery risks, radiation exposure in hybrid OR included in list

November 20, 2013 — Each year, ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care, offers a patient safety service to the healthcare community. The 2014 Top 10 Health Technology Hazards list raises awareness of the potential dangers associated with the use of medical devices and helps healthcare providers minimize the risk of technology-related adverse events.  
 
The 2014 list highlights the top 10 safety topics that warrant particular attention for the coming year. A 16-page executive brief about the hazards is available for free on ECRI’s website. It describes safety issues resulting from the following 10 technologies:
 
  1. Alarm hazards
  2. Infusion pump medication errors
  3. Computed tomography (CT) radiation exposure in pediatric patients
  4. Data integrity failures in electronic health records (EHRs) and other health information technology (IT) systems
  5. Occupational radiation hazards in hybrid ORs
  6. Inadequate reprocessing of endoscopes and surgical instruments
  7. Neglecting change management for networked devices and systems
  8. Risks to pediatric patients from “adult” technologies
  9. Robotic surgery complications due to insufficient training
  10. Retained devices and unretrieved fragments
 
Clinical alarm hazards remain at the top of the list due to their prevalence, their potential to result in serious patient harm and the increased attention they will receive from the Joint Commission in the coming year. In an April 2013 Sentinel Event Alert, the Joint Commission cited 98 alarm-related events over a 3.5-year period, with 80 of those events resulting in death and 13 in permanent loss of function. The organization subsequently issued a National Patient Safety Goal for 2014 to compel healthcare providers to address alarm hazards. ECRI has developed resources and tools to help providers meet the provisions of this new goal, and it offers an alarm management safety review consulting service.     
 
New topics this year include hazards related to radiation exposure in hybrid ORs and complications arising from insufficient training in the application of robotic surgery. The list also includes two hazards describing risks to pediatric patients: CT radiation dose and the use of technologies designed for adults.
 
“Technology safety can often be overlooked,” says James Keller Jr., vice president, health technology evaluation and safety, ECRI Institute. “Based on our experience, there are serious safety problems that need to be addressed. ECRI recommends that hospitals use our list as a guide to help prioritize their technology-related safety initiatives.”
 
To develop the annual list, ECRI and ECRI patient safety organization (PSO) engineers, scientists, nurses, physicians and patient safety analysts draw on the resources of the institute’s 45-year history, as well as their own expertise and insight gained through analyzing healthcare technologies. This includes examining health technology-related problem reports from hospitals and health systems worldwide as well as those received through federally designated patient safety organization, ECRI PSO.
 
Complementing the annual list is ECRI’s Web-based Health Technology Hazard Self-Assessment Tool, which provides a facility- or department-specific risk factor rating of low, medium, or high related to each of the top 10 hazards. The tool also provides targeted recommendations for mitigating the risks associated with each of the top 10 hazards.   
 
A more comprehensive discussion of each hazard, additional recommendations for minimizing the risks and a list of useful resources for more information about each topic are provided in the November 2013 issue of Health Devices.
 
For more information: www.ecri.org, www.jointcommission.org

Related Content

cybersecurity, healthcare industry, SecurityScorecard report, social engineering, cyberattacks
News | Information Technology| October 31, 2016
SecurityScorecard, a security rating and continuous risk monitoring platform, released its 2016 Healthcare Industry...
GE Healthcare, Revolution CT, Whisper Drive, RSNA 2016, cardiac imaging
News | CT Angiography (CTA)| October 31, 2016
At the 2016 annual meeting of the Radiological Society of North America (RSNA 2016), GE Healthcare will introduce the...
RFID inventory control in the cath lab, inventory management, cardinal

An example of RFID cabinets in a cath lab. As items are pulled from the cabinet, the inventory control system automatically determines what items were take out and adds them to the patient case. The system can also help locate recalled or expired items, and automatically track on-hand inventory to avoid manual counts.

Feature | Inventory Management| October 28, 2016 | Jean-Claude Saghbini
The healthcare industry’s transition to value-based care leaves no room for waste, and yet we know that inefficiency
Sponsored Content | Videos | Inventory Management| October 28, 2016
With quality of care and cost efficiency at the top of your mind, there is no room in your hospital for waste from hi
medicare bundled cardiac payments, CMS cardiology payments
Feature | Business| October 24, 2016 | By John W. Meyer, MPH, FACHE
(Editor’s note: This is the second part of a two-part series on the proposed Medicare five-year demonstration for
Toshiba CT, picking a CT scanner, choosing a CT scanner, CT 101, what to look for in CT scanners, Aquilion ONE ViSION

The Toshiba Aquilion One Vision system is among the new generation of CT systems on the market that offers several dose lowering technologies and a hardware/software combination to enhance image quality over previous-generation scanners.

Feature | CT Angiography (CTA)| October 14, 2016 | Dave Fornell
As hospitals begin replacing their first-generation 64-slice computed tomography (CT) scanners after a decade of use,
Sci-image, Scimage, CVIS, CIIMS, Cpacs c-pacs, cardiovascular information system

Today's cardiovascular information systems need to incorporate all facets of the cardiology department, including subspecialties, to allow a complete picture of a patient's record. These data also need to be able to be shared with enterprise data systems, such as the electronic medical record (EMR). This image is from ScImage, illustrating the various aspects that integrate to make up a complete CVIS. 

 

Feature | September 29, 2016 | Val Kapitula, RT(R), PMP, CIIP
Cardiovascular information and imaging systems (CVIS) have existed for many years in the dedicated sub-specialty area
ACC, American College of Cardiology, Google search, heart conditions, Health Knowledge Graphs
News | Information Technology| September 23, 2016
A Google search for heart conditions will now prominently display important questions patients should ask their doctor...
Sponsored Content | Videos | Inventory Management| September 21, 2016
With bundled payments putting increased pressure on hospitals to manage supply costs while providing quality patient
don woodlock, GE Healthcare, EP CVIS, electrophyiology
Sponsored Content | Webinar | Cardiac PACS| September 16, 2016
Cardiac rhythm management (CRM) data is becoming increasingly important in the management of patients with implantabl
Overlay Init