ECRI's top health tech hazards for 2020 include EHR errors, alert fatigue, missing MRI data

The annual report from ECRI Institute spotlights the Top 10 technology dangers in hospitals, ambulatory clinics and LTPAC settings.
By Mike Miliard
01:05 PM

Timing-related EHR errors, which could delay the administration of critical medications if the order generated doesn't match the dose administration time intended by the prescriber, were one of the risks noted on this year's list.

For its new annual assessment of healthcare technology dangers, the nonprofit safety group ECRI Institute points to misuse of surgical staplers as the top hazard. But a few major health IT risks also round out the list.

ECRI's Top 10 Health Technology Hazards for 2020 is meant to keep healthcare leaders informed about the patient safety risks they should be prioritizing.

The hazards it highlights are chosen based on ECRI's own incident investigations, public and private incident reporting databases, medical device testing and more.

The 2020 edition of the ECRI list is topped by the potential for misuse of surgical staplers to cause harm to patients.

Earlier this year, the U.S. Food and Drug Administration published an analysis of nearly 110,000 stapler incidents over the past eight years – including 412 deaths, 11,181 serious injuries, and 98,404 malfunctions.

ECRI itself has investigated 75 stapler accidents, some of them fatal, and published 42 safety alerts.

"Injuries and deaths from the misuse of surgical staplers are substantial and preventable," said Dr. Marcus Schabacker, president and CEO of ECRI Institute. "We want hospitals and other medical institutions to be in a better position to take necessary actions to protect patients from harm."

But three health IT-related risks were also on the list.

Alert fatigue and notification overload – long familiar to physicians, nurses and others delivering frontline care and, more recently, to healthcare infosec pros too – was at the No. 6 spot. Missing implant data and MRIs, which leaves clinicians in the dark about implantable devices and can put patients in danger thanks to delayed scans, was listed at No. 8.

And timing-related medication errors in the electronic health record – which ECRI notes can delay the administration of critical medications if the order generated by the EHR doesn't match the dose administration time intended by the prescriber – were listed at No. 9.

ECRI Institute's Top 10 Health Technology Hazards list is now in its 13th year. In past years, IT-related concerns included errors that can arise when IT configurations and facility workflow are out of sync, misuse of USB ports that can cause medical devices to malfunction and software management gaps that put patients and data at risk.

Here's the full list for 2020:

  • Surgical stapler misuse – malfunctions and misuse can lead to patient harm.
  • Point-of-care ultrasound – speed of adoption has outpaced policies and practices that could prevent misuse or misdiagnosis. 
  • Sterile processing errors in medical/dental offices – failure to consistently and effectively sterilize contaminated items can lead to patient infections.
  • Central venous catheter risk in at-home hemodialysis – risks associated with CVCs can be particularly dangerous in the home setting, where family members may be ill-equipped to manage the risks.
  • Unproven surgical robotic procedures – surgical robots are being used for an expanding range of procedures, sometimes before the risks have been fully assessed. 
  • Alarm, alert, and notification overload – high number of notifications can overwhelm clinicians, creating the potential for a significant event to go unaddressed.
  • Connected home healthcare security risks – interruption in transfer of patient monitoring data from cybersecurity issues can lead to misdiagnosis or delayed care.
  • Missing implant data and MRIs – being unaware of a patient's implant information can put patients in danger and delay MRI scans.
  • Medication timing errors in EHRs – critical medications can be delayed if the order generated from the EHR does not match the dose administration time intended by the prescriber.
  • Loose nuts and bolts in devices – failure to maintain nuts and bolts on medical equipment can lead to catastrophic accidents, harming patients, clinicians or bystanders. 

Schabacker notes in this year's report that "what used to be hospital problems are now concerns in ambulatory and home care settings.

"As healthcare shifts outside the hospital, ECRI remains committed to building awareness about technology hazards to keep patients safe," he said.

Twitter: @MikeMiliardHITN
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Healthcare IT News is a publication of HIMSS Media.

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