Health Technology Hazards in Hospitals

"Technology safety can often be overlooked," says James P. 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 Institute recommends that hospitals use our list as a guide to help prioritize their technology-related safety initiatives."

The 2015 Top 10 Health Technology Hazards report, available for download as a free public service, 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 on the 2015 list include:

• 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 mis-administration 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
• Cyber-security: Insufficient protections for medical devices and systems
• Overwhelmed recall and safety alert management programs

For the fourth year in a row, clinical alarm hazards, a Joint Commission National Patient Safety Goal, remains number one on ECRI's list. 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, which appears on the list for the first time, 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. 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. Materials that are available to members of ECRI Institute's Health Devices , Health Devices Gold , and SELECTplus programs are listed under the "Member Resources" heading. Materials that are more broadly available or that require subscriptions to other services are listed as "Additional Resources."

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.

To download the report for free, visit www.ecri.org/2015hazards

For questions about ECRI Institute's annual list of technology hazards, or for information about ECRI Institute's membership programs, accident investigation services, or adverse event reporting, contact ECRI Institute by telephone at (610) 825-6000, ext. 5891; by e-mail at clientservices@ecri.org; or by fax at (610) 834-1275.

ECRI Institute (www.ecri.org), a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs, and processes are best to enable improved patient care. As pioneers in this science for 45 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. Strict conflict-of-interest guidelines ensure objectivity. ECRI Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute PSO is listed as a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services.