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ECRI releases 2015 top 10 health technology hazards list

by Lauren Dubinsky, Senior Reporter | November 26, 2014
ECRI Institute released their 2015 top 10 health technology hazards yesterday and alarm hazards made it to number one for the fourth consecutive year. Incorrect or missing EHR data and IV line issues that cause drugs to be administered incorrectly followed close behind.

In past lists, ECRI discussed a broad range of issues that could lead to clinical alarm hazards, but this year they homed in on hazardous alarm configuration practices. They noted that in their experience, missed alarms or unrecognized alarm condition are often associated with those practices.

Alarm configuration practices include everything from deciding what alarms should be enabled to establishing the default alarm priority level. If the right settings are not selected, then the caregiver may be exposed to an excess of alarms or they might not even be notified if there is a valid alarm.

In order to prevent that, ECRI recommends that a facility establish a policy for standard alarm configuration practices based on specific care areas. The policy includes default parameter alarm and volume settings that satisfy the patient demographics, clinical indications and needs of that specific care area and the processes for changing the settings, and for ensuring that the right settings are used when moving the patients to a different area.

Inaccurate or incomplete information in the EHR can potentially lead to incorrect treatment decisions. Data integrity can be compromised when one patient's data is entered into another patient's record, when there is missing data or delayed data delivery due to network limitations, clock synchronization issues among different devices, etc.

ECRI recommends that before a new system is implemented, the facility should analyze how the front-line staff will use it in order to determine if there is any potential for error. Once the system is implemented, the facility should have their staff go through a comprehensive training program.

The EHR and other HIT systems should be thoroughly tested to ensure that they are fully implemented and working the way they are intended to. Staff should also be included in the testing process.

Infusion pump programming errors are not something new to the list but this year, ECRI decided to specifically focus on the issues that are associated with administering multiple IV infusions to one patient.

The wrong line could be connected to a fluid container, which would deliver the incorrect fluid to the patient. It could also deliver the fluid to the wrong place - it was supposed to be for IV delivery but was delivered into an epidural catheter, for example.

To prevent those issues, ECRI recommends that the caregivers trace each line from the fluid container to ensure that it's connected to the right administration site. They also recommend labeling each line with the name of the drug it's administering and to not force a connection if it's difficult to make.

The other hazards on the list include insufficient endoscope and other surgical instrument reprocessing, when a ventilator disconnection is not caught because of alarm errors, improper use of patient-handling devices, unnoticed variations in diagnostic radiation doses, lack of adequate training for robotic surgery, cybersecurity issues and overburdened recall and safety-alert management.

"Technology safety can often be overlooked," James P. Keller, Jr., vice president of health technology evaluation and safety at ECRI said in a statement. "Based on our experience, there are serious safety problems that need to be addressed."

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