ECRI Institute’s Top 10 Health Technology Hazards for 2016 (Part 1)

Published on January 1, 2015

Medical technology has helped make improvements in patient care and outcomes for years, but as technology advances, new risks have come with it. Every year, patients are harmed in hospitals by unexpected technology hazards. That’s why ECRI Institute releases an annual list of top 10 health technology hazards aimed at identifying possible sources of danger or difficulty with certain technologies so that healthcare facilities can take steps to minimize the likelihood of adverse events.

Although it’s extremely important for healthcare professionals to read this list, we at Knapp & Roberts Law Firm believe it’s equally as important that patients know the risks, as well. The ECRI Institute notes in the report 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 first 5 on the list for 2016:

1.) Inadequate cleaning of flexible endoscopes before disinfection can spread deadly pathogens. We’ve written about this risk before on our blog. The failure to adequately clean, disinfect and sterilize contaminated instruments (such as endoscopes) before using them on other patients can lead to the spread of deadly pathogens. ECRI Institute’s report notes that flexible endoscopes and duodenoscopes are of specific concern due to their complex design and long, narrow channels that can make effective cleaning difficult. Because of this, facilities need to emphasize and perhaps even reconsider the processes currently in place to reduce the likelihood of this avoidable, and often fatal, medical error happening to patients.

2.) Missed alarms. Countless patients have died or have been seriously injured due to a failure to recognize and respond to an actionable clinical alarm condition in a timely manner. This could be due to an alarm condition that is not detected by a medical device (such as a physiologic monitor, ventilator, or infusion pump), or when a condition is detected, but it was not successfully communicated to the medical staff, or when a condition is communicated, but is not appropriately addressed due to a failure to notice the alarm or by medical staff blatantly choosing to ignore an alarm. ECRI Institute suggests a comprehensive alarm management program that includes stakeholders from throughout the organization.

3.) Failure to effectively monitor postoperative patients for opioid-induced respiratory depression. First, let’s define what some of these words mean. An opioid is a drug used to relieve pain, such as morphine, hydromorphone, oxycodone, or fentanyl. They work by reducing the intensity of pain signals reaching the brain and affect the brain areas that control emotion, diminishing the pain stimulus.

Respiratory depression is when you have a slow respiratory rate that does not provide for full expansion of the lung, or does not provide enough oxygen to the tissues. This can lead to severe injury like anoxic brain injury, or even death. Patients at higher risk include those who are also receiving another drug that has sedating effects, those who have a condition that predispose them to respiratory compromise, such as morbid obesity or sleep apnea, and medication errors that result in the delivery of more medication than intended – this can be due to medical staff error or a technological error in which a machine gives the wrong dose, concentration, or medication.

4.) Inadequate surveillance of monitored patients in telemetry settings. Telemetry is the electronic transmission of data between distant points, used in monitoring biological signs of medical importance such as EKG, ECG, and EOG. With inadequate surveillance in these settings, patients are at serious risk.

Factors contributing to this problem include the incorrect assumption by medical staff and organizations that monitoring systems can reliably detect all potentially lethal arrhythmias, the use of these systems in care areas where patients are not as closely supervised (such as areas with higher nurse-to-patient ratios), and when patient monitoring information is only displayed at the central station, where events may be missed if staff is not present to observe the patient data, or if staff is distracted. According the ECRI Institute, this risk can be minimized by, “educating personnel about the limitations of monitoring technology and the factors that could lead to missed events, as well as implementing measures to improve patient surveillance.”

5.) Insufficient training of clinicians on operating room (OR) technologies. ECRI Institute estimates that 70% of accidents involving a medical device can be attributed to user error or a mistake in the technique of use. These mistakes result in prolonged surgery, complications requiring additional treatment, serious injury, and even death. ECRI Institute suggests that facilities, “make training a key part of the acquisition process for new OR technologies, as well as an ongoing consideration for existing technologies.”

For the next 5 health technology hazards for 2016, please click here. Please don’t hesitate to 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.