Top Health Technology Patient Safety Hazards for 2018

Top Health Technology Patient Safety Hazards for 2018


Published: January 25th, 2018

ECRI Institute, a non-profit research organization, recently released its annual Top 10 List of Health Technology Hazards for 2018. The purpose of this report is to inform healthcare facilities about the important safety issues involving the use of health technology and bring attention to potential sources of danger. The full report includes practical strategies hospitals and healthcare providers can take to help reduce patient safety risks.

The following is the list of top Health IT Safety Hazards for 2018:  

  1. Ransomware and Cybersecurity Threats Can Put Patients at Risk- Ransomware has been one of the most globally talked about issues facing healthcare organizations today. This malware can disrupt healthcare delivery operations and the delivery of care, placing patients in danger. Protection against malware attacks requires an organization to take a proactive approach through senior management, clinical engineering, IT professionals, and other key individuals.
  2. Endoscope Reprocessing Failures Expose Patients to Infection Risk- Failure to consistently and effectively reprocess (clean and sterilize) flexible endoscopes can lead to the spread of deadly infections. To achieve more reliable and effective endoscope reprocessing, ECRI Institute recommends that healthcare facilities: (1) establish processes for assessing the quality of the cleaning step such as, through magnification-aided visual inspections and the use of biochemical testing (2) implement measures to dry endoscope channels after reprocessing.
  3. Mattresses and Covers Infected with Contaminants May Put Staff and Patients at Risk- Bed and stretcher mattresses often remain contaminated after they have been cleaned, which puts patients and staff at risk of exposure.  To safeguard against this risk, companies that sell or rent mattress covers must recommend cleaning and disinfecting materials that will remove the contaminants without compromising the cover’s integrity. Healthcare facilities should also use appropriate materials and procedures for cleaning and disinfecting mattress covers. It is also necessary to regularly inspect mattresses and mattress covers for signs of damage or contamination.
  4. Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems- Secondary alarm notification systems send alarms and other relevant alerts from a medical device or IT system to a clinician’s smartphone or other communication device. They are intended to send timely notifications to the appropriate clinician. However, sometimes configuration or management problems with the systems can lead to alarm delivery delays or failures. This can lead to missed alarm conditions, delayed care, and avoidable patient harm. Avoiding such problems requires care during system configuration, verification and validation during implementation, and assessments of system integrity periodically during use.
  5. Improper Cleaning May Cause Device Malfunctions, Equipment Failures, and Potential for Patient Injury-  Incompatible cleaning agents or unapproved cleaning methods used on medical devices and other equipment can result in device malfunctions and safety issues, that lead compromised patient care. The need to stock and use multiple cleaning products, along with the requirement to familiarize staff with device-specific cleaning methods, is a significant burden for hospitals. Nevertheless, the risk of harm to patients and staff, and the substantial costs to replace damaged devices, can sometimes outweighs the challenge of implementing safe and correct cleaning.
  6. Unholstered Electrosurgical Active Electrodes Can Lead to Patient Burns- Electrosurgical unit (ESU) active-electrode pencils that are not safely holstered between activations can lead to burns or fires if the ESU is inadvertently activated. Proper and consistent use of the safety holsters that are typically supplied with active-electrode pencils can prevent such incidents. In fact, ECRI Institute’s data shows, the added costs associated with holster use are minimal.
  7. Inadequate Use of Digital Imaging Tools, May Lead to Unnecessary Radiation Exposure- Imaging technologies play a vital role in modern medicine, but have inherent risks that must be managed. Exposure to high doses of ionizing radiation, can increase a patient’s long-term risk of developing cancer. While extremely high doses during an individual procedure can cause radiation burns. Imaging departments and facilities should investigate dose-control strategies and provide users with the training and support they need to gain confidence using newer tools and techniques.
  8. Improper Practices Using Bar-Coded Medication Administration Systems- Bar-coded medication administration (BCMA) systems help clinicians verify at the point of care that the medications to be administered match provider orders. Used the right way, these systems can prevent dangerous medication errors. Used incorrectly, BCMA’s safety advantages can be completely negated. Improper practices include administering medications before using the bar-code scanner, scanning patient bar codes from a list of stickers on a clipboard instead of from the patient wristband, and preparing medications for more than one patient at a time. Maximizing the safety benefits of BCMA requires minimizing the circumstances that can lead to improper use. To do this, give careful thought to system implementation, verify that staff understand the importance of performing the multistep workflow correctly, and maintain the system so that all the component devices and systems function properly.
  9. Flaws in Medical Device Networking Can Lead to Delayed or Inappropriate Care- Inattention to best practices for implementing networked medical devices and information systems can lead to incorrect or incomplete data transfers and other data communication errors. Such errors can delay diagnosis or treatment or prompt a misdiagnosis, affecting patient safety. With more and more medical devices and information systems being connected through hardwired or wireless networks, it has become increasingly important for healthcare facilities to assess, approve, and implement changes to these networked medical devices and information systems in a controlled manner.
  10. Slow Adoption of Safer Enteral Feeding Connectors Can Leave Patients at Risk- Enteral feeding tubing can be inadvertently connected to patient lines intended for other purposes, sometimes with fatal consequences. A newly available, standards-based connector design for enteral feeding systems—known by its trademarked name, ENFit—can help prevent such misconnections. To date, healthcare facilities have been slow to adopt enteral devices with ENFit connectors, primarily due to concerns over the availability of components bearing the new connectors. However, this situation has improved, and a successful transition is now possible. ECRI Institute and other organizations recommend that healthcare providers throughout the world transition to enteral devices with ENFit connectors as soon as practicable


More information about the ECRI ranking is available on the group's website. https://www.ecri.org/Pages/2018-Hazards.aspx