ECRI identifies top 10 health technology hazards for 2010

By Jeff Marion
02:56 PM

Superior healthcare technology usually means better care and safety for patients – but the familiar technologies that power today's modern hospitals also have a dark side. From infections to cancer to surgical fires, this list covers the top 10 healthcare technology threats for 2010.

Released by the ECRI Institute, a Plymouth Meeting, Pa.-based federal patient safety organization, the list was derived from investigations into device-related incidents, as well as from a medical device problem reporting database maintained by ECRI and other organizations.

ECRI released the top five items on the list in a press release, and referred readers to the company's Web site for a complete list.

ECRI officials say the report doesn't identify a one-size-fits-all solution to all problems, but identifies the most crucial issues facing hospitals. While the dangers described in the report are real and often frightening, the good news is that most risks are preventable. Hospitals should reevaluate their to-do lists and consider putting these recommendations at the top to avoid bad practices before they result in patient harm.

The top five items on the list are:

1. Cross-Contamination from Flexible Endoscopes

Endoscopy is a minimally invasive medical diagnostic procedure that has revolutionized care in modern hospital settings. However, it has also caused medical personnel to expose their patients to infectious diseases. The cause often results from failure to adhere to cleaning and sterilization procedures. Often in these cases, large numbers of patients must be notified of exposure to contaminated endoscopic equipment.

To prevent risk, hospitals should:

  • Develop and adhere to comprehensive, model-specific reprocessing protocols;
  • Ensure that model-specific reprocessing protocols exist for each flexible endoscope model; and
  • Ensure that any automated endoscope reprocessors (AERs) are compatible with the disinfecting agent, the appropriate channel adapters are available, and staff adhere to maintenance schedules.

2. Alarm Hazards

Clinical alarms warn caregivers of hazard, and are instrumental in preventing patient injury or death as long as caregivers get the message. Alarm issues are among the most frequently reported problems, mostly due to the sheer variety of equipment – patient monitoring, ventilators, dialysis units and many others.

To avoid potential risks:

  • Avoid alarm fatigue by configuring alarm limits to appropriate, physiologically meaningful values;
  • Look for designs that limit nuisance  (false or excessive) alarms, which can desensitize staff; and
  • Consider implementing an alarm-enhancement system to increase alarm volume or convey alarms remotely.

3. Surgical Fires

In September, Janice McCall, 65, was killed in a flash fire in the operating room as she was undergoing routine surgery at Heartland Regional Medical Center in Marion, Ill. Some 550 to 650 surgical fires occur annually, according to the latest estimates from ECRI, making them roughly as frequent as other surgical mishaps like wrong-site surgery. Most surgical fires result from the presence of an oxygen-enriched atmosphere during surgeries to the head, face, back and upper chest.

New recommendations include:

  • With certain exceptions, the traditional practice of open delivery of 100 percent oxygen should be discontinued during head, face, back, and upper-chest surgery.
  • Hospitals should implement a surgical fire prevention and management program.
  • Each member of the surgical team should clearly understand the role played by oxidizers, ignition sources, and fuels – the classic fire triangle in the operating room.

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4. CT Radiation Dose

With recent articles in the New England Journal of Medicine indicating many CT studies expose patients to an unnecessary risk of cancer, and a report in October that Cedars-Sinai Medical Center in Los Angeles accidentally used extremely high radiation doses during CT stroke scans on more than 200 patients, the risks of CT scanning have become a major concern. In the United States alone, CT is thought to be responsible for about 6,000 additional cancers a year.

To avoid potential risks:

  • Make sure the expected benefits of a CT study outweigh the radiation risks.

  • In most modern systems, the dose can be reduced by up to 80 percent. Adjust CT acquisition parameters to allow the required clinical information to be obtained with the lowest possible dose.
  • CT precations are especially important for pediatric patients – for whom the cancer risk is as much as triple that for a 30-year-old – and pregnant women.
  • Ensure that technologists performing CT exams are trained specifically for CT and that they maintain their training and certification.

5. Retained Devices and Unretrieved Fragments

Another frequent source of reports to ECRI and the U.S. Food and Drug Administration are items left inside patients following treatment. These take the form of retained devices, where an entire device is unknowingly left behind, and unretrieved device fragments in which a portion of a device breaks away and remains inside the patient. While often benign, if a patient later undergoes magnetic resonance examination, retained metal can heat or migrate, resulting in burns or worse.

To prevent risks:

  • Inspect devices before use. If a device appears damaged, don't use it.
  • Be alert for significant resistance during device removal, which could indicate that the device is trapped and at risk of breaking.
  • Inspect devices as soon as they are removed from the patient.

ECRI offers the complete list of top 10 hazards as a downloadable PDF on their site (see sidebar for link).