HIT systems among top 10 health tech hazards, says ECRI

By Erin McCann
11:05 AM

Health IT may promise a new paradigm of patient care, but it's also fraught with complexity and the potential for error. A new report from ECRI Institute, which researches best practices to improve care delivery, outlines the top 10 health technology hazards for 2013, and health IT systems are disconcertingly close to the top.

ECRI's 6th annual “Top 10 Health Technology Hazards list” is designed to raise awareness of the potential dangers associated with the use of medical devices and systems. A popular roadmap for healthcare providers to prioritize their technology safety initiatives, the list features key topics that warrant particular attention for the coming year with actionable recommendations on addressing them.  

The top 10 hazards listed in ECRI Institute’s report are:

  1. Alarm hazards
  2. Medication administration errors using infusion pumps
  3. Unnecessary radiation exposures and radiation burns during diagnostic radiology procedures
  4. Patient/data mismatches in EHRs and other health IT systems
  5. Interoperability failures with medical devices and health IT systems
  6. Air embolism hazards
  7. Inattention to the needs of pediatric patients when using “adult” technologies
  8. Inadequate reprocessing of endoscopic devices and surgical instruments
  9. Caregiver distractions from smartphones and other mobile devices
  10. Surgical fires

[See also: ECRI names top 10 healthcare tech dangers.]

Three of the 10 topics on the list are directly associated with the still-maturing health IT field, where the interplay between complexity and effectiveness and potential harm is most evident; several of the other topics are peripherally related to HIT issues.
“The inherent complexity of HIT-related medical technologies, their potential to introduce new failure modes, and the possibility that such failures will affect many patients before being noticed – combined with federal incentives to meet meaningful use requirements – leads us to encourage healthcare facilities to pay particular attention to health IT when prioritizing their safety initiatives for 2013,” says James P. Keller, Jr., vice president, health technology evaluation and safety, ECRI Institute.

One particularly “troubling” aspect regarding patient/data mismatches in EHRs and other health IT systems, the report reads, “is that some of the capabilities that make health IT systems so powerful – their ability to collect data from and transmit data to a variety 
of devices and systems, for example – can serve to multiply the effects of such errors to a degree that would have been unlikely in a paper-based system.”

"Healthcare organizations are receiving financial incentives from the U.S. government to rapidly adopt this technology," added Keller. "As with any computer-based system they provide tremendous benefits but errors in using the software or software bugs can cause serious problems."

With regard to number five on the list – interoperability failures with medical devices and health IT systems – the report cites many instances where invalid lab results, due to improper procedures, were correctly eliminated from one system but still visible in another system, such as an EHR.

“Like with the health IT data mismatch problems, interoperability between devices and information systems is just starting to get off the ground and there are not real good mechanisms for reporting interoperability problems," Keller told Healthcare IT News. "We’ve included this item on our list to alert healthcare organizations to the kinds of interoperability problems that can occur and have been reported and to emphasize the need to incorporate important risk management standards as they are implementing their interoperability projects.”

As for number nine on the list – caregiver distractions from smartphones and other mobile devices – the report cites the 2011 case study by John Halamka, MD, now CIO at Beth Israel Deaconess Medical Center, where a physician was using her smartphone to enter an order for a patient to discontinue anticoagulation therapy. The physician received a text in the middle of completing the order, responded to the text, then neglected to finish the order. Eventually, with the continued anticoagulation therapy, the patient developed life-threatening conditions and needed open-heart surgery.

The hazards included in the 2013 list, published in the November 2012 issue of ECRI Institute’s Health Devices journal, met one or all of the following criteria: it has resulted in injury or death; it has occurred frequently; it can affect a large number of individuals; it is difficult to recognize; it’s had high-profile, widespread news coverage. Lastly, there must be clear steps for hospitals to take now to minimize these risks.  
Complementing the annual list is ECRI Institute’s Web-based Health Technology Hazard Self-Assessment Tool, which provides a facility or department risk factor ratings of low, medium, or high related to each of the Top 10 hazards. Healthcare organizations can then use the information to help prioritize their efforts to address the hazards. The tool also provides facility- and department-specific recommendations for mitigating the risks associated with each of the Top 10 hazards.    

The Top 10 Health Technology Hazards list is updated each year based upon the prevalence and severity of incidents reported to ECRI Institute by healthcare facilities nationwide; information found in the Institute’s medical device problem reporting databases; and the judgment, analysis, and expertise of the organization’s multidisciplinary staff.

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