Devices & Technology

Diligence Needed to Avoid the Top 10 Health Technology Hazards for 2011

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By Christina Orlovsky, contributor 

December 27, 2010 - As health care facilities continue to embrace new technology to enhance patient care and improve efficiency in the workplace, one organization is reminding health care providers that technology is not always a panacea. In fact, health technology devices and systems have their own unique risks.

Emphasizing that “most adverse events involving health technology are preventable, but they need to be clearly understood and thoughtfully acted upon,” ECRI Institute, a Plymouth Meeting, Pennsylvania-based nonprofit organization that provides research toward the improvement of health care, recently published its annual list of the Top 10 Health Technology Hazards.

“We publish the Top 10 list every year to raise awareness in hospitals about the serious medical technology hazards that we have been reporting on for many years,” explained James P. Keller, Jr., vice president, health technology evaluation and safety for the ECRI Institute.

ECRI’s Top 10 list is updated each year based on the prevalence and severity of incidents reported to ECRI Institute by health care facilities nationwide, as well as information found in the institute’s medical device problem-reporting databases and the judgment, analysis and expertise of the organization’s multidisciplinary staff.

ECRI’s list of top 10 hazards for 2011 include:

1. Radiation overdose and other dose errors during radiation therapy
2. Alarm hazards
3. Cross-contamination from flexible endoscopes
4. The high radiation dose of CT scans
5. Data loss, system incompatibilities and other health IT complications.
6. Luer misconnections
7. Oversedation during use of PCA infusion pumps
8. Needlesticks and other sharps injuries
9. Surgical fires
10. Defibrillator failure in emergency resuscitation attempts

“All of the items on the Top 10 list are important for any health care professional who works with health care technologies,” Keller said. “The items that nurses would likely have the most impact on helping to improve include the alarm hazards, Luer misconnections, oversedation during use of PCA infusion pumps, and needlesticks and other sharps injuries.” 

Along with the list, ECRI Institute includes recommendations for providers to avoid or overcome these hazards. For alarm hazards, for example, the organization advises that health care professionals do the following: examine the entire alarm environment when setting up a facility’s alarm-management program; establish protocols for alarm-system setting, including defining default alarm settings for specific care units and modifications for specific patients; establish alarm-response protocols to ensure each alarm will be recognized, delivered to an appropriate responder and properly addressed; and establish policies to control alarm silencing, modification and disabling.

To avoid the hazards of Luer misconnections, ECRI recommends: providing periodic training about misconnection prevention; prohibiting the use of adapters; reviewing purchasing policies to ensure that products incorporate misconnections safeguards; identifying and managing conditions that may contribute to health care worker fatigue; requiring that clinical staff trace all lines back to their origin before making connections, then recheck connections and trace tubes and catheters to their sources upon patient handoffs.

For all of the hazards, however, Keller advises that a full understanding of the technology is the key to successful – and safe – implementation and utilization within the health care environment.

“The most important thing that caregivers can do is to make sure that they fully understand the technologies that they are using, and especially the risks associated with those technologies. If you don’t feel comfortable with using a medical device or believe that you don’t fully understand its risks, please let your superiors know so that appropriate training can be arranged,” he concluded. “Finally, make sure to speak up if you think that one or more of your colleagues may be unclear about the use of a technology or if you observe an unsafe condition with its use. Administrators should make sure that their clinical staff have been provided with the appropriate support to help them confidently and safely use today’s complex technologies.”

For more information or to download the full report, visit the ECRI Institute.

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