12 Worst Medical Technology Dangers

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Technology provides benefits to patients, but it also brings significant risks that can threaten patient safety. The ECRI Institute of Plymouth Meeting, Pennsylvania, an independent nonprofit organization that studies improvements to patient care, has named the Top Health Technology Hazards for 2012. (We also include 2 hazards from the prior year.)

Each hazard met 1 or more of the following criteria: It has resulted in injury or death; it has occurred frequently; it can affect a large number of people; it has been widely publicized; and there must be steps that hospitals can take to lessen the risks.

Technology provides benefits to patients, but it also brings significant risks that can threaten patient safety. The ECRI Institute of Plymouth Meeting, Pennsylvania, an independent nonprofit organization that studies improvements to patient care, has named the Top Health Technology Hazards for 2012. (We also include 2 hazards from the prior year.) Each hazard met 1 or more of the following criteria: It has resulted in injury or death; it has occurred frequently; it can affect a large number of people; it has been widely publicized; and there must be steps that hospitals can take to lessen the risks. "With so many health technologies being used, it can be difficult for hospitals to prioritize their safety efforts," says James P. Keller, Jr., ECRI Institute's Vice President, Health Technology Evaluation and Safety. "Our list can be used as a guide to help them focus on the most important issues." Image Courtesy of Getty/Thinkstock

"With so many health technologies being used, it can be difficult for hospitals to prioritize their safety efforts," says James P. Keller, Jr., ECRI Institute's Vice President, Health Technology Evaluation and Safety. "Our list can be used as a guide to help them focus on the most important issues." Image Courtesy of Getty/Thinkstock

"Alarm Fatigue" Hazards Alarms on medical devices, such as infusion pumps, ventilators, and dialysis units, are designed to warn of potential dangers to patients. But alarms can contribute to adverse events. One major reason is "alarm fatigue." The staff may become desensitized to the frequency with which alarms are sounded and become complacent, delaying needed action. The problem is similar to that of car alarms: When they go off constantly, people tend to ignore them. "There is rapid growth in the use of medical devices with alarms," says Keller. "In a noisy ICU, it's easy for a clinician to miss one." To reduce alarm-related incidents, ECRI recommends, "Establish protocols that ensure that each alarm will be recognized, that the appropriate caregiver will be alerted, and that the alarm will be promptly addressed." Hospitals should determine who is responsible for responding to alarms and notify them. Image Courtesy of Getty/Thinkstock

"Alarm Fatigue" Hazards Alarms on medical devices, such as infusion pumps, ventilators, and dialysis units, are designed to warn of potential dangers to patients. But alarms can contribute to adverse events. One major reason is "alarm fatigue." The staff may become desensitized to the frequency with which alarms are sounded and become complacent, delaying needed action. The problem is similar to that of car alarms: When they go off constantly, people tend to ignore them. "There is rapid growth in the use of medical devices with alarms," says Keller. "In a noisy ICU, it's easy for a clinician to miss one." To reduce alarm-related incidents, ECRI recommends, "Establish protocols that ensure that each alarm will be recognized, that the appropriate caregiver will be alerted, and that the alarm will be promptly addressed." Hospitals should determine who is responsible for responding to alarms and notify them. Image Courtesy of Getty/Thinkstock

Exposure Dangers From Radiation Therapy and CT Life-saving radiation therapy can have devastating consequences if errors occur. Likewise, inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Adverse events are probably underreported. "There isn't a good reporting system in place to define what is a reportable event," says Keller. Hospitals need to maintain adequate staffing levels and quality assurance procedures. For radiation therapy, facilities need to ensure that staff follow and document standard patient treatment procedures, including double-checks and time-outs, and develop standard checklists. For CT safety, it's important for radiologists and medical physicists to be accessible to all clinical staff regarding appropriate use of diagnostic imaging. In addition, those involved should make sure that radiation doses are as low as possible while maintaining image quality. Image Courtesy of Getty/Thinkstock

Exposure Dangers From Radiation Therapy and CT Life-saving radiation therapy can have devastating consequences if errors occur. Likewise, inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Adverse events are probably underreported. "There isn't a good reporting system in place to define what is a reportable event," says Keller. Hospitals need to maintain adequate staffing levels and quality assurance procedures. For radiation therapy, facilities need to ensure that staff follow and document standard patient treatment procedures, including double-checks and time-outs, and develop standard checklists. For CT safety, it's important for radiologists and medical physicists to be accessible to all clinical staff regarding appropriate use of diagnostic imaging. In addition, those involved should make sure that radiation doses are as low as possible while maintaining image quality. Image Courtesy of Getty/Thinkstock

Medication Administration Errors When Using Infusion Pumps Mistyping information, entering it into the wrong field, and other data-entry mistakes can be dangerous or even fatal. Doctors, nurses, pharmacists, and others can contribute to errors. Medication orders may be illegible, drugs and solutions may be incorrectly prepared, and a medication may be given to the wrong patient. "One way to avoid errors is to use a dose-error-reduction system," says Keller. "It has built-in limits, or guardrails. If a nurse enters a dose that exceeds the limit, an alert will occur to catch the error before it can happen." It's crucial to determine the compatibility of the pumps with your safety systems. Get the names of other sites that have integrated the pump with information systems from the major providers. For staff who will be using the system, emphasize the importance of safeguards, and be aware of any resistance to new workflows and safety compliance issues. Image Courtesy of Leslie Kane

Medication Administration Errors When Using Infusion Pumps Mistyping information, entering it into the wrong field, and other data-entry mistakes can be dangerous or even fatal. Doctors, nurses, pharmacists, and others can contribute to errors. Medication orders may be illegible, drugs and solutions may be incorrectly prepared, and a medication may be given to the wrong patient. "One way to avoid errors is to use a dose-error-reduction system," says Keller. "It has built-in limits, or guardrails. If a nurse enters a dose that exceeds the limit, an alert will occur to catch the error before it can happen." It's crucial to determine the compatibility of the pumps with your safety systems. Get the names of other sites that have integrated the pump with information systems from the major providers. For staff who will be using the system, emphasize the importance of safeguards, and be aware of any resistance to new workflows and safety compliance issues. Image Courtesy of Leslie Kane

Cross-contamination From Flexible Endoscopes Improper cleaning and disinfection techniques of flexible endoscopes can lead to patient cross-contamination, resulting in life-threatening infections. It is essential to adhere to a multistep procedure for reprocessing endoscopes. Any missed step could compromise the process. "We learned of a case where a brand of colonoscope changed its design and required independent cleaning of a new channel for it to be fully disinfected," says Keller. "The hospital didn't realize that, so it treated patients with endoscopes that weren't fully disinfected." Make sure to review instructions before purchase to help identify and avoid devices that are complicated. Have a specific reprocessing protocol for each flexible endoscope. Ask the manufacturer of the device to identify unique requirements for cleaning and sterilization. Image Courtesy of Getty/Thinkstock

Cross-contamination From Flexible Endoscopes Improper cleaning and disinfection techniques of flexible endoscopes can lead to patient cross-contamination, resulting in life-threatening infections. It is essential to adhere to a multistep procedure for reprocessing endoscopes. Any missed step could compromise the process. "We learned of a case where a brand of colonoscope changed its design and required independent cleaning of a new channel for it to be fully disinfected," says Keller. "The hospital didn't realize that, so it treated patients with endoscopes that weren't fully disinfected." Make sure to review instructions before purchase to help identify and avoid devices that are complicated. Have a specific reprocessing protocol for each flexible endoscope. Ask the manufacturer of the device to identify unique requirements for cleaning and sterilization. Image Courtesy of Getty/Thinkstock

Failing to Pay Sufficient Attention to New Device Connectivity Medical technology and information technology (IT) can create risks. Hazards can arise from software problems, interoperability between systems, and poor network performance. Problems could create a domino effect, in which changes to one component of the system affect the operation of another. Potential problems also include issues about wireless networks, cybersecurity, and software upgrades. "Hospitals must stay on top of routine updates," says Keller. ECRI's recommendations: Make sure that hardware and software changes, security changes, and planned maintenance are approved and implemented in a controlled manner. Because IT help desks are usually the first point of contact for problems with health IT, provide the help desk team with education, training, and clear escalation procedures. Image Courtesy of Getty/Thinkstock

Failing to Pay Sufficient Attention to New Device Connectivity Medical technology and information technology (IT) can create risks. Hazards can arise from software problems, interoperability between systems, and poor network performance. Problems could create a domino effect, in which changes to one component of the system affect the operation of another. Potential problems also include issues about wireless networks, cybersecurity, and software upgrades. "Hospitals must stay on top of routine updates," says Keller. ECRI's recommendations: Make sure that hardware and software changes, security changes, and planned maintenance are approved and implemented in a controlled manner. Because IT help desks are usually the first point of contact for problems with health IT, provide the help desk team with education, training, and clear escalation procedures. Image Courtesy of Getty/Thinkstock

Feeding Tube Misconnections The most serious mistake occurs when nutrients intended for the gastrointestinal tract are inadvertently delivered elsewhere, such as the vasculature. This mistake can cause death, usually by embolus or sepsis. The US Food and Drug Administration (FDA) has urged making connectors and adaptors uniform, so that built-in incompatibility will prevent misconnections. Color-coding was also recommended. Making such changes is voluntary, however, and feeding tube misconnections continue. Whenever possible, use enteral pumps for enteral feeding, says Keller. Trace lines from end to end when making an initial connection or reconnection. Don't modify or adapt intravenous or feeding devices, which could compromise their safety features. Label or color-code feeding tubes and connectors. Purchase only feeding sets that meet ANSI/AAMI ID54 standards. Image Courtesy of Getty/Thinkstock

Feeding Tube Misconnections The most serious mistake occurs when nutrients intended for the gastrointestinal tract are inadvertently delivered elsewhere, such as the vasculature. This mistake can cause death, usually by embolus or sepsis. The US Food and Drug Administration (FDA) has urged making connectors and adaptors uniform, so that built-in incompatibility will prevent misconnections. Color-coding was also recommended. Making such changes is voluntary, however, and feeding tube misconnections continue. Whenever possible, use enteral pumps for enteral feeding, says Keller. Trace lines from end to end when making an initial connection or reconnection. Don't modify or adapt intravenous or feeding devices, which could compromise their safety features. Label or color-code feeding tubes and connectors. Purchase only feeding sets that meet ANSI/AAMI ID54 standards. Image Courtesy of Getty/Thinkstock

Surgical Fires There are an estimated 600 surgical fires in the United States each year, almost all avoidable. They can cause fatal airway burns and facial disfigurement. To avoid surgical fires, each member of the surgical team must understand the role played by oxidizers, ignition sources, and fuels in the operating room. Implement a surgical fire prevention program. To minimize the risks of oxygen-enriched atmospheres, implement new clinical recommendations on oxygen delivery. Discontinue the practice of open delivery of 100% oxygen during head, face, neck, and upper chest surgery. Only air should be used for open delivery to the face, if the patient can maintain safe blood oxygen saturation without supplemental oxygen. The surgical team should have a time-out before starting surgery and assess any fire risks. "We emphasize the need for team members to speak up if they have any doubt," says Keller. Image Courtesy of Getty/Thinkstock

Surgical Fires There are an estimated 600 surgical fires in the United States each year, almost all avoidable. They can cause fatal airway burns and facial disfigurement. To avoid surgical fires, each member of the surgical team must understand the role played by oxidizers, ignition sources, and fuels in the operating room. Implement a surgical fire prevention program. To minimize the risks of oxygen-enriched atmospheres, implement new clinical recommendations on oxygen delivery. Discontinue the practice of open delivery of 100% oxygen during head, face, neck, and upper chest surgery. Only air should be used for open delivery to the face, if the patient can maintain safe blood oxygen saturation without supplemental oxygen. The surgical team should have a time-out before starting surgery and assess any fire risks. "We emphasize the need for team members to speak up if they have any doubt," says Keller. Image Courtesy of Getty/Thinkstock

Needlesticks and Other Sharps Injuries Needlesticks are still a serious problem, exposing health professionals to bloodborne pathogens. A recent survey saw a sharps injury rate among hospital workers in Massachusetts of 28 injuries per year per 100 occupied beds. Another study found that passive safety-engineered devices were significantly more effective than those that were manually activated. ECRI's recommendations: An effective sharps safety program must include input from diverse stakeholders. Facilities should annually review their safety efforts. Assess injuries and current practices to help identify where and when injuries occur. During which procedures or applications are injuries most likely to occur? Establish an action plan that specifies who is responsible for implementation, when milestones should be completed, and what the goals are. Train all personnel on all shifts. Image Courtesy of Getty/Thinkstock

Needlesticks and Other Sharps Injuries Needlesticks are still a serious problem, exposing health professionals to bloodborne pathogens. A recent survey saw a sharps injury rate among hospital workers in Massachusetts of 28 injuries per year per 100 occupied beds. Another study found that passive safety-engineered devices were significantly more effective than those that were manually activated. ECRI's recommendations: An effective sharps safety program must include input from diverse stakeholders. Facilities should annually review their safety efforts. Assess injuries and current practices to help identify where and when injuries occur. During which procedures or applications are injuries most likely to occur? Establish an action plan that specifies who is responsible for implementation, when milestones should be completed, and what the goals are. Train all personnel on all shifts. Image Courtesy of Getty/Thinkstock

Anesthesia Dangers From Mistakes in Pre-use Inspection Serious problems with anesthesia equipment occur frequently. Reports include misconnected breathing circuits, ventilator leaks, and empty gas cylinders. In practice, pre-use inspections can be inconsistent and incomplete. Hospital staffs sometimes conduct checks using obsolete or generic procedures, says Keller. Staff may skip a portion of the inspection if they don't understand its importance. ECRI's recommendations: Before the day's first case, staff members should perform an equipment inspection that includes the model-specific, manufacturer-prescribed full check of the anesthesia unit. Before each subsequent case, make sure that the unit is inspected according to the manufacturer's instructions. Staff members should know who is responsible for performing the check. Image Courtesy of Getty/Thinkstock

Anesthesia Dangers From Mistakes in Pre-use Inspection Serious problems with anesthesia equipment occur frequently. Reports include misconnected breathing circuits, ventilator leaks, and empty gas cylinders. In practice, pre-use inspections can be inconsistent and incomplete. Hospital staffs sometimes conduct checks using obsolete or generic procedures, says Keller. Staff may skip a portion of the inspection if they don't understand its importance. ECRI's recommendations: Before the day's first case, staff members should perform an equipment inspection that includes the model-specific, manufacturer-prescribed full check of the anesthesia unit. Before each subsequent case, make sure that the unit is inspected according to the manufacturer's instructions. Staff members should know who is responsible for performing the check. Image Courtesy of Getty/Thinkstock

Problems With Home Use Medical Devices Approximately 7.6 million people in the United States receive medical care in their homes. Some devices used in the home are designed for use in hospitals by trained professionals, says Keller. Problems may go undetected. The FDA has identified 3 challenges: caregiver knowledge, environmental unpredictability, and device usability. Many of the devices used in the home are older and have no labeling or instructions for use or maintenance. ECRI's recommendations: Assess the patient and caregivers before prescribing any medical device, to ensure that everyone involved in the patient's care can use the technology appropriately. Reassess the patient regularly and after a clinical event. Make sure patients get education materials. When patients leave the hospital, be sure that they have contact information for the hospital or the home health agency. Make sure that patients and their caregivers know how to use the equipment. Image Courtesy of Getty/Thinkstock

Problems With Home Use Medical Devices Approximately 7.6 million people in the United States receive medical care in their homes. Some devices used in the home are designed for use in hospitals by trained professionals, says Keller. Problems may go undetected. The FDA has identified 3 challenges: caregiver knowledge, environmental unpredictability, and device usability. Many of the devices used in the home are older and have no labeling or instructions for use or maintenance. ECRI's recommendations: Assess the patient and caregivers before prescribing any medical device, to ensure that everyone involved in the patient's care can use the technology appropriately. Reassess the patient regularly and after a clinical event. Make sure patients get education materials. When patients leave the hospital, be sure that they have contact information for the hospital or the home health agency. Make sure that patients and their caregivers know how to use the equipment. Image Courtesy of Getty/Thinkstock

Defibrillator Failure The FDA reports many incidents in which defibrillators failed to work properly. Often, they didn't discharge during resuscitation attempts for preventable reasons, such as depleted batteries. To make sure that defibrillators are ready at a moment's notice, hospitals must perform regular preventive maintenance and conduct daily checks recommended by the supplier. ECRI recommends that hospitals ensure that the clinicians who are responsible for using the defibrillator during a resuscitation attempt perform checks at least daily. Verify that the installed battery is charged and that a charged spare battery is kept with the unit. Verify that between uses, the unit (or charger) is plugged in and batteries are charging. If you note error codes during routine checks or at any other time, take corrective action or contact the clinical engineering department. Image Courtesy of Getty/Thinkstock

Defibrillator Failure The FDA reports many incidents in which defibrillators failed to work properly. Often, they didn't discharge during resuscitation attempts for preventable reasons, such as depleted batteries. To make sure that defibrillators are ready at a moment's notice, hospitals must perform regular preventive maintenance and conduct daily checks recommended by the supplier. ECRI recommends that hospitals ensure that the clinicians who are responsible for using the defibrillator during a resuscitation attempt perform checks at least daily. Verify that the installed battery is charged and that a charged spare battery is kept with the unit. Verify that between uses, the unit (or charger) is plugged in and batteries are charging. If you note error codes during routine checks or at any other time, take corrective action or contact the clinical engineering department. Image Courtesy of Getty/Thinkstock

Luer (Tubing and Catheter) Misconnections Tubing and catheter misconnections can allow gases or liquids to enter the wrong lines, often severely injuring patients, such as when fluid meant for an enteral feeding tube enters an intravenous catheter. These risks increase when 2 functionally dissimilar devices each use Luer connectors. To prevent such mishaps, conduct periodic training of everyone working in patient care. Prohibit use of adapters, which can permit the connection of 2 components that normally wouldn't mate. Review purchasing policies to allow only products that include misconnection safeguards. Require that clinical staff trace all lines back to their origin before making connections, and recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival in a new setting or service as part of the handoff process. Image Courtesy of Getty/Thinkstock

Luer (Tubing and Catheter) Misconnections Tubing and catheter misconnections can allow gases or liquids to enter the wrong lines, often severely injuring patients, such as when fluid meant for an enteral feeding tube enters an intravenous catheter. These risks increase when 2 functionally dissimilar devices each use Luer connectors. To prevent such mishaps, conduct periodic training of everyone working in patient care. Prohibit use of adapters, which can permit the connection of 2 components that normally wouldn't mate. Review purchasing policies to allow only products that include misconnection safeguards. Require that clinical staff trace all lines back to their origin before making connections, and recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival in a new setting or service as part of the handoff process. Image Courtesy of Getty/Thinkstock

Author Mark Crane Freelance writer Brick, New Jersey Image Courtesy of Getty/Thinkstock Related Content on Medscape: 10 Medical Errors That Changed the Standard of Care

Author Mark Crane Freelance writer Brick, New Jersey Image Courtesy of Getty/Thinkstock Related Content on Medscape: 10 Medical Errors That Changed the Standard of Care

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