2. Alarm fatigue

Nurses and staff are overwhelmed by alarms -- this can lead them to ignore, or even turn off, vitally important notifications. One such case at Massachusetts General Hospital earlier this year possibly led to a man's death after his heart monitor was turned off, according to a Boston Globe report. The paper said an ECRI search of the FDA's adverse event database found 237 reported alarm-related deaths from 2002 to 2004. ECRI said most alarm events involve physiologic monitoring systems and ventilators.


1. Radiation therapy errors

Topping this year's list is the danger of radiation therapy errors. Radiation therapy is used in about half of all cancer treatments. High doses of radiation and complex treatment protocols mean errors can be deadly, as evidenced by the tragic tales covered in a New York Times series that ran earlier this year.

The increasing complexity of the treatments leave plenty of room for human error -- reports estimate that up to 60 percent of all mistakes are due to people, and not the technology. One example cited by ECRI is treating a patient with a plan actually belonging to someone else with a similar sounding name. However, software is also often to blame. ECRI said a database search revealed 40 reports of software-related errors from summer 2009 to summer 2010. Overall, more than 3,000 patients have been affected by radiotherapy adverse events over the past three decades, according to a 2008 World Health Organization literature review. Of these, about 1 percent have died from overdose toxicity. Still, the published error rate remains low. A Cleveland Clinic review in 1995 found the crude radiation delivery error rate to be around one in 555. But ECRI said because the consequences of an overdose are not always immediately apparent it's possible the true error rate is underreported.


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