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ECRI Institute’s Top 10 Health Technology Hazards for 2016 (Part 2)

Published on January 3, 2016

Medical malpractice is among the top three leading causes of death in the United States—just after heart disease and cancer. New technologies are released every year hoping to minimize the likelihood of life-changing injuries or death happening to patients, but often times these technologies introduce new risks. That’s why every year, the ECRI Institute releases its list of the top 10 health technology hazards for 2016. In our last blog post, we shared the first 5 risks. Today, we’re sharing the rest.

Please note that this is not a list of the most frequently reported problems or the ones with the most severe consequences, it is a list of risks that the ECRI Institute’s Health Devices Group believes should be a priority now. Here are the last 5 health technology hazards for 2016:

6.) Poor alignment between the configuration of a health IT (HIT) system and facility workflow. When a facility’s workflow and health IT system do not support each other, it can lead to issue such as: missed information or the inability to find needed information within the HIT system, the mistaken application of default values – such as dosing, time, or orders – instead of the correct/desired values, input errors, and more. Because of this, it can also lead to medical errors, putting patients at risk. ECRI Institute suggests that facilities, “consider configuration issues during the HIT system selection phase and should modify/validate workflows to confirm that they align with the system’s capabilities.”

7.) Unsafe injection practices. Both in hospitals and outpatient settings, unsafe injection practices can happen resulting in disease transmission, serious injury, and death. Some of those risky practices include: reusing a needle or syringe that had been used to administer medication, sharing an insulin pen among patients, using a single-dose medication vile for multiple patients, or failing to use aseptic technique when preparing, handling and injecting medications. Solutions to unsafe injection practices involve education and action by frontline healthcare workers, by the leadership of hospitals, outpatient clinics and skilled nursing facilities, and by patients.

8.) Gamma camera mechanical failures. The gamma camera is an imaging machine used to carry out functional scans of the brain, thyroid, lungs, liver, gallbladder, kidneys and skeleton. They incorporate heavy, moving components that can cause significant harm if they rotate into or fall onto a patient or staff member. ECRI Institute and FDA have received multiple reports of mechanical failures involving these cameras resulting in serious injuries and in one case, death.

This is why gamma camera systems should be properly maintained and why all safety-related recalls should be addressed in a timely manner. In the past two years, more than 40 gamma camera safety recalls have been filed with the FDA. This is why facilities should advise staff not to leave patients unattended in the gamma camera scan room. They should also maintain, service and inspect gamma cameras in accordance with the manufacturer’s guidance, and verify that all current recalls and safety notices have been acted on.

9.) Failure to appropriately operate intensive care ventilators. A ventilator is also known as a respirator or breathing machine. It’s used to deliver breaths to a patient who is unable to effectively breath on their own. These machines may be used temporarily or permanently (as in long term care). Inappropriate patient ventilation can cause ventilator-induced lung injury (VILI), and can lead to death.

Lung-protective strategies (such as using a lower tidal volume) have been developed and advanced ventilator modes and features are available to aid clinicians in providing safer and more effective ventilation. However, all too often, these techniques and tools are not used, are not used to their full advantage, or best practices are not assessed and adopted by facilities. These injuries can be prevented by continually educating staff on the best practices for patient ventilation, and ensuring understanding of complex ventilator functionality, including terminology associated with the device and operation of the device itself.

10.) Misuse of USB Ports. This is a strange one to consider on the patient side, but some medical devices have USB ports. Plugging unauthorized devices or accessories into these ports can cause the medical device to malfunction, shut down, slow its performance, change its settings, and is a security risk, putting the patient’s data and healthcare facility’s systems at risk. ECRI Institute suggests that facilities develop and implement a policy on the appropriate use of USB ports on medical devices.

To download a free PDF of the 2016 Top 10 Health Technology Hazards report, click here.

Please share this article with friends and family. The more we educate ourselves as patients, the better prepared we can be to ask healthcare professionals pointed questions aimed at a safe outcome for our loved ones and ourselves.

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