Earlier this week, HCB News visited ECRI Institute in Pennsylvania to get a deeper understanding of the items on its annual list of the top health technology hazards for 2017.

The topics on the list are chosen by weighing factors such as the severity, frequency, breadth, insidiousness, and profile of the hazard — and they all have at least one thing in common: they can be avoided with appropriate measures.

"Technology safety can often be overlooked when hospital leaders are dealing with so many other issues," said David T. Jamison, executive director of ECRI's Health Devices Group, in a statement. "As an independent medical device testing laboratory and investigator of technology-related incidents, we know what can go wrong and what steps hospitals can take to reduce patient harm, related to specific technologies and processes."

A different perspective on infusion pump danger

Infusion pump errors made it to number one, but this time for a different reason. In the past there was a focus on software safety features and integrating the pump with the EMR, but this time around ECRI is bringing attention to common nurse practices that are overlooked.

“These are all things that are simple and don’t cost anything, and nurses have been doing them for 20 to 30 years,” Erin Sparnon, manager of the Health Devices Group at ECRI, said in a workshop. “But sometimes it can be forgotten if they’re spending so much time thinking about the new technology.”

Sparnon recommends that nurses check the drip chamber in order to ensure that the infusion is flowing at the correct rate. For example, if the pump says that the flow is 30 milliliters per hour but it looks like 1,000 milliliters per hour then clearly there is an issue here that needs fixing.

Even though the automatic free flow clamp closes off the infusion when the set is being removed, the nurse should use the roller clamp as well. The nurses should also inspect the pump for damage before starting an infusion.

Sparnon said that nurses should ask themselves these questions:

• Are there any cracks on the outside of the door?


• When the door is open, does it look right or is something hanging to the side?


• When loading the administration set, does it feel right or does it feel like something is jammed?

“Infusion pumps are one of the most numerous devices in the hospitals. We have hundreds or even thousands of these scattered across the hospital,” said Juuso Leinonen, project office of the Health Devices Group at ECRI. “They are oftentimes subject to pretty rough handling, and as a result you may have damage to various parts of the pump.”

Unique infection risks with cardiothoracic surgery

Unique infection risks with cardiothoracic surgery

A hazard that hospitals might not foresee is infection risks that heater-cooler devices for cardiothoracic surgery pose. These devices have been identified as a potential source of nontuberculous mycobacteria infections, and are listed as the fifth top hazard on the 2017 list.

Although this is a rare hazard, it can be life-threatening and there have been cases in which it resulted in patient deaths.

These devices warm or cool the patient by extracorporeal heat exchange with the patient’s blood during heart-lung bypass procedures. Warm or cold water is circulated through a closed circuit and if the device is contaminated, it can cause NTM infections.

ECRI recommends that hospitals only use filtered water in these machines, and that the air flow is directed away from the patient during surgery. These machines can cost between $30,000 and $40,000, and once they are contaminated, it’s impossible to decontaminate them.

Device failures caused by cleaning products and practices

Device failures caused by cleaning products and practices

Another costly hazard is medical device failure due to the use of incompatible cleaning products. To date, hospitals have lost tens of thousands of dollars from this.

An improper cleaner can damage seals, degrade equipment surfaces and cause fluid intrusion. At one hospital, a couple of cracks appeared on a surgical arm and then they spread until the machine eventually crumbled apart.

“The hospital said it looked like someone took a hammer and broke the parts,” said Jaime Schlorff, senior project officer of the Health Devices Group at ECRI. “You don’t see plastic degrading before your eyes. It starts small and you don’t realize it’s happening until it’s too late.”

Manufacturers are working closely with ECRI to issue alerts to customers. The main challenge is that there are 286 manufacturers that offer medical device cleaning products.

There is no single cleaner that will work on all devices, so hospitals have to stock up on multiple cleaning products and educate the staff on the proper cleaning methods. It’s a laborious task, but not doing so can lead to costly device failures.

“Hospitals aren’t always aware of this and that’s where we come in,” said Schlorff.