Compliance News: ECRI Institute Lists 2013's Top 10 Health Technology Hazards

Compliance News:  ECRI Institute Lists 2013's Top 10 Health Technology Hazards 

by David Stymiest, PE, CHFM, CHSP, FASHE

The ECRI Institute recently published a 25-page special report entitled “ECRI Institute 2013 Top 10 Health Technology Hazards” – available at www.ecri.org/2013hazards. In its introduction, ECRI encourages facilities to use the list of generic hazards as a “starting point for patient safety discussions and for setting their health technology safety priorities.” This report is comprehensive with a multitude of useful recommendations along with exhaustive lists of further reference publications. We recommend that our readers use the link above to acquire their own copies of the ECRI publication for review and possible action.

ECRI stated that it considered a number of factors in determining which hazards actually made it to the top 10 list, including potential for harm, frequency/likelihood of the hazard, how widespread is the hazard, whether the problem is difficult to recognize or challenging to rectify, and whether the hazard has a high profile in the media.

 The hazards discussed by ECRI are listed below, and a few of them are further discussed in this article. Several of the hazards on the 2013 list have been listed by ECRI in previous years. Most of these hazards are also receiving attention from The Joint Commission and other authorities having jurisdiction. Many of these hazards can fall under multiple Environment of Care (EOC) areas and require oversight by hospital EOC and Safety Committees.

1. Alarm hazards
2. Medication administration errors using infusion pumps
3. Unnecessary exposures and radiation burns from 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

ECRI is not alone in highlighting the problematic issue of medical device alarm fatigue. The Association for the Advancement of Medical Instrumentation (AAMI) Foundation’s Healthcare Technology Safety Institute also tackled this issue in 2012, building on priorities identified at the high level multi-organization Fall 2011 Medical Device Alarms Summit. The Joint Commission surveyed its accredited organizations in 2012 to assess its own future activities, and the US Food and Drug Administration is also addressing challenges related to medical device alarm fatigue.

Medication administration errors using infusion pumps can be reduced, according to ECRI, by “integrating infusion pumps with electronic ordering, administration, and documentation systems.”  ECRI further cautions that this will “require considerable involvement from clinical engineers, IT staff, and other technology managers.” The report also addresses other recommended activities.

In its discussion of unnecessary exposures and radiation burns from diagnostic radiology procedures, ECRI goes beyond earlier discussions regarding CT procedures to any diagnostic imaging procedure. In the report, ECRI recommends attention to staffing; quality assurance and quality control procedures with peer review; attention to installation, acceptance testing, commissioning and maintenance of systems; and several other areas.

The issue of inadequate reprocessing of endoscopic devices and surgical instruments has been an ECRI focus in past years as well. This issue is also targeted by TJC and has been one of the commonly-cited areas during 2012 TJC surveys. Although not mentioned in the ECRI report, even reprocessing area ventilation pressure relationships have been cited by TJC.

ECRI stated that surgical fires are on its 2013 top 10 list because ECRI receives at least one report of a surgical fire each week despite previous focused attention. TJC’s Sentinel Event Alert Issue 29 entitled Preventing Surgical Fires also addressed this topic in detail. ECRI states that “virtually all surgical fires can be avoided” and recommends enhanced training and communication about the risks and roles of oxidizers, ignition sources and fuels in the OR. ECRI’s report also has additional recommendations for changes in practices to reduce or eliminate the risk of surgical fires moving forward.