ECRI releases top 10 list of deadly technology hazards

Dirty scopes at the top
By Bernie Monegain
09:41 AM
Alarm signal

ECRI Institute has released its 2016 list of worst technology hazards occurring today. The goal of the annual list, say ECRI leaders, is to inform healthcare facilities about important safety issues involving the use of medical devices and systems. Any of the items listed on the top 10 list could be deadly.

In an incident at UCLA Medical Center in February 2015, at least two patients died, and 179 were exposed to superbug CRE, carbapenem-resistant Enterobacteriacea.

At UCLA, the suspect devices were endoscopes inserted down the throats of about 500,000 patients annually to treat cancers, gallstones and other ailments of the digestive system. The CDC has said the design of the scopes make them difficult to clean.

The month before the UCLA deaths, Virginia Mason Medical Center in Seattle acknowledged that 32 patients were sickened by contaminated endoscopes from 2012 to 2014 with a bacterial strain similar to CRE, resulting in 11 deaths.

[See also: Two dead, 179 exposed to superbug at UCLA Medical Center.]

ECRI's 2016 list of top 10 dangers

  1. Inadequate cleaning of flexible endoscopes before disinfection can spread deadly pathogens
  2. Missed alarms can have fatal consequences
  3. Failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death
  4. Inadequate surveillance of monitored patients in a telemetry setting may put patients at risk
  5. Insufficient training of clinicians on operating room technologies puts patients at increased risk of harm
  6. Errors arise when HIT configurations and facility workflow do not support each other
  7. Unsafe injection practices expose patients to infectious agents
  8. Gamma camera mechanical failures can lead to serious injury or death
  9. Failure to appropriately operate intensive care ventilators can result in preventable ventilator-induced lung injuries
  10. Misuse of USB ports can cause medical devices to malfunction

[See also: Top 10 patient safety concerns from ECRI .]

ECRI leaders note that just because a topic on a previous year's list isn't included on the 2016 list, it shouldn't be interpreted to mean the topic no longer deserves attention. Most of these hazards persist.

ECRI Institute engineers, scientists, clinicians, and other patient safety analysts nominate topics for consideration based on their own expertise and insight gained through:

  • Investigating incidents
  • Testing medical devices
  • Observing operations and assessing hospital practices
  • Reviewing literature
  • Speaking with clinicians, clinical engineers, technology managers, purchasing staff, health systems administrators and device suppliers
  • Staff also consider the thousands of health-technology-related problems

"With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked," says Anthony Montagnolo, chief operating officer, ECRI Institute, in a press statement. "Based on our experience with independent medical device testing in our laboratory, accident investigations and reported events, we're very aware of serious safety problems that occur."

The not-for-profit ECRI aims to bring the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs and processes enable better patient care.

Download the full report.

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