News | December 04, 2014

ECRI Institute Announces Top 10 Health Technology Hazards for 2015

“Dose creep” in X-ray radiation listed among hazards

radiation dose management, ECRI, top 10 hazard list

Image courtesy of ECRI

December 4, 2014 — To help hospitals reduce technology-related risks, ECRI Institute publishes an annual list of Top 10 Health Technology Hazards.

The 2015 hazards list highlights 10 safety topics and details a variety of technology hazards that put patients at risk.

Each hazard includes an overview of the issue and recommended action steps to aid healthcare facilities in their efforts to maintain a safe environment for patients and healthcare workers. Topics include:

 

1.      Alarm hazards: Inadequate alarm configuration policies and practices

2.      Data integrity: Incorrect or missing data in electronic health records and other health IT systems

3.      Mix-up of IV lines leading to misadministration of drugs and solutions

4.      Inadequate reprocessing of endoscopes and surgical instruments

5.      Ventilator disconnections not caught because of mis-set or missed alarms

6.      Patient-handling device use errors and device failures

7.      “Dose creep”: Unnoticed variations in diagnostic radiation exposures

8.      Robotic surgery: Complications due to insufficient training

9.      Cybersecurity: Insufficient protections for medical devices and systems

10.    Overwhelmed recall and safety alert management programs

 

This year, the report draws particular attention to alarm configuration practices. ECRI Institute is aware of several deaths and other cases of severe patient harm that may have been prevented with more effective alarm policies and practices.

Recall management points to overwhelmed recall and safety-alert programs as a potential for serious consequences for healthcare facilities and patients. ECRI experts are concerned that existing hospital recall tracking programs are not keeping pace with the growing number of medical device recalls issued each year. The U.S. Food and Drug Administration (FDA) reports that the annual number of medical device recalls nearly doubled between 2003 and 2012, from 604 recalls to 1,190 annually.

For each topic, ECRI Institute describes the hazard, presents recommendations for minimizing the risks, and lists helpful resources that readers can access to learn more about the topic.  

To develop the annual list, ECRI Institute’s multidisciplinary staff of engineers, scientists, nurses, physicians and patient safety analysts draw on the resources of the Institute’s 45-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. This includes examining health technology-related problem reports from hospitals and health systems worldwide, and reports received through ECRI Institute Patient Safety Organization.

For more information: www.ecri.org

 

Related Content

Dianna Bardo, M.D., oversees a pediatric CT scan at Phoenix Children’s Hospital. She uses technology to help lower CT X-ray radiation dose when scanning children.

The CT scanner might not come with protocols that are adequate for each hospital situation so at Phoenix Children’s Hospital they designed their own protocols, said Dr. Dianna Bardo, director of body MR and co-director of 3D Innovation Lab at Phoenix Children’s. She said they shared these protocols as part of their partnership with Philips Healthcare. 

Sponsored Content | Case Study | Radiation Dose Management | June 07, 2018
Radiation dose management is central to child patient safety. Medical imaging plays an increasing role in the accurat
Radiation dose monitoring for angiography on the Canon Infinix angiography system. Radiation dose tracking in cardiology.

An example of a real-time patient radiation dose tracking system available for Canon's angiography imaging system. Systems like this can show cumulative dose to the patient's skin as a reminder to rotate the C-arm to new positions to prevent burns during long procedures. These types of systems also can help track patient dose and the location of that dose to be included as part of their electronic patient record. This data also enables quality assurance assessments.

Feature | Radiation Dose Management | June 01, 2018 | Dave Fornell, Editor
A new consensus document on how to mitigate radiation exposure in cardiac imaging for both patients and staff was iss
Nuclear cardiology SPECT scan showing myocardial perfusion. A new consensus document issues by ACC and other societies provides guidelines on managing radiation dose.
Feature | Radiation Dose Management | May 31, 2018 | Dave Fornell, Editor
May 31, 2018 — Here is a checklist of dose-sparing practices for nuclear cardiology that was included in a new 2018 c
A patient injuried by extreme exposure to X-ray radiation during an angiography procedure, which is included among the images in the American College of Cardiology (ACC) consensus document. Angiography skin burn.

A patient injured by extreme exposure to X-ray radiation during an angiography procedure, which is included among the images in the consensus document. Severe skin injury typically appears four to eight weeks following the exposure. In extreme cases, the ulceration can become confluent and full thickness necrosis of skin may develop, exposing underlying fat, muscle and even bone.

 

News | Radiation Dose Management | May 10, 2018
May 10, 2018 — A new consensus document has been issued to guide the optimal use of ionizing radiation in cardiovascu
The Egg Medical EggNest cath lab patient table is designed with passive protection designed to drastically reduce scatter radiation exposure for the entire cath lab team without disruption to workflow.
Technology | Radiation Dose Management | May 10, 2018
We started our design from the ground up, tested many prototypes, did not want to compromise on radiation protection
Mirion Technologies Introduces Instadose Radiation Dosimeter
Technology | Radiation Dose Management | February 08, 2018
The Instadose + dosimeter, the latest by Mirion Technologies, transforms...
EHRA Highlights Occupational Risk of Radiation Exposure in Electrophysiology Procedures
News | Radiation Dose Management | February 01, 2018
February 1, 2018 –Stereotaxis, who makes innovative...
ACR Chair Tells House Subcommittee to Fund Modern Low-Dose Medical Radiation Research
News | Radiation Dose Management | November 01, 2017
James A. Brink, M.D., FACR, chair of the American College of Radiology (ACR) Board of Chancellors, met with the House...
Technology | Radiation Dose Management | September 07, 2017
September 7, 2017 — Sapheneia and Scannerside received U.S.
Virtual Phantoms Inc. Releases VirtualDose-IR
Technology | Radiation Dose Management | August 07, 2017
Virtual Phantoms Inc. announced the release of VirtualDoseIR, a tool for assessing organ dose from interventional...
Overlay Init