6. Tube mix-ups

Mistakenly plugging the wrong tube into the wrong place can be deadly. This summer, the New York Times reported on a case where a young pregnant woman and her baby died after nutrients meant for a feeding tube to the gut instead were delivered into a tube that entered the woman's vein. Between Jan. 2008 and Sept. 2009, a Pennsylvania patient safety data registry received 36 reports of tube misconnections, some having serious medical consequences, ECRI said.


5. Health IT errors

The growth of health information technology promises some new hazards. Medical devices frequently transmit important patient health information. ECRI says there's a risk of data getting lost or becoming linked with the wrong patient. In testimony delivered in February, the FDA's device division reported there have already been 260 HIT-related events over the past two years, including 44 injuries and six deaths.

4. CT scan radiation

Making a return to the list this year is concern over radiation from CT scans. CT scans are one of the main contributors to the rise in medical radiation to patients over the past few decades. Although a recent presentation at the Radiological Society of North America's meeting in Chicago suggested the number of cancers caused by ionizing radiation delivered from the scans might be vastly overestimated, other research is grimmer: a 2009 study argued that the scans done in 2007 alone could result in 29,000 new cancers. And while new technology that reduces dose can help, it's not always an option, the institute noted. "Unfortunately, the most advanced technologies are generally available only on the latest, and most expensive, CT systems, and many health care facilities simply cannot afford to purchase top-of-the-line scanners," ECRI said.

3. Improperly cleaned endoscopes

"Hello Mrs. Smith - I'm calling to follow up on your recent colonoscopy. The colonoscope used in your procedure might have been contaminated. Can you come in for HIV and Hepatitis testing?" read a slide in an ECRI presentation last year dubbed "A Patient's Nightmare." Cross-contamination of patients from improperly sterilized flexible endoscopes remains a serious problem, the institute said. A 2009 Veterans Affairs inspection found that fewer than half of its facilities selected for the review properly sterilized colonoscopy equipment, according to the Washington Post. Last year, the agency had to contact more than 10,000 patients over possible exposure to HIV and hepatitis. However, in a report, the VA said the overall infection risk from a GI endoscopy was thought to be low: only one in 1.8 million procedures.

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