What are the Top 10 Technology Hazards in 2014? (Part 2 of 2)

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MTR-thumb1Yesterday, we began our look at the ECRI Institute‘s list of the top 10 technology hazards in 2014, as reported by Cheryl Clark for HealthLeaders Media. We conclude today by reviewing the top five hazards.

At No. 5 on the list is “occupational radiation hazards in hybrid ORs.”

This item on the list has been magnified in its urgency since hospitals began “moving sophisticated imaging equipment into the operating room in order to conduct angiography even during minimally invasive procedures.”

While this is a convenient and seemingly sensible allocation of resources, it could be enhancing “the risk of ionizing radiation exposure to health-care workers who may not have experience working in such settings as do their colleagues in radiology or catheterization labs.”

The solution to this hazard, ECRI says, is knowledge: of the risks, of precautions that can be taken, and of effective monitoring of the potential hazards.

The next item on the list, No. 4, is “data integrity failure in EHRs and other health IT systems.”

Clark writes, “While electronic health record adoption has tripled between 2009 and 2012 in response to federal financial incentives and penalties, and more is underway, the opportunities for error with these systems is significant.”

Some errors listed by ECRI are: patient/data association errors, missing data, delayed data delivery, clock synchronization errors, dual workflows, copying and pasting old info into a new report, and basic-data entry mistakes.

According to Clark, “This hazard is similar to a hazard described in last year’s report, which noted that even moving a patient from one room to another could result in that patient’s medical data being sent to the wrong medical record.”

No. 3 on the list involves “CT radiation exposures in pediatric patients.”

This is also a recurring feature on the ECRI list, and this year ECRI is especially concerned with “CT in children because of concerns that ionizing radiation can be especially risky to growing human tissue.” The report cautions against the “use of adult doses of radiation for children, and use of lower-radiation alternatives such as MRI, ultrasound, and X-rays, and avoiding repeat scans by checking on whether a CT has been done recently at another institution.”

At No. 2 on the list is “infusion pump medication errors.”

“Hospitals may have thousands of these pumps, whose misuse or failure produce more adverse incident reports to the FDA than any other medical technology,” Clark writes. “Because some patients are highly sensitive to fluids and drugs they receive through these pumps, wrong dosages can be lethal. Some 710 deaths were reported to the FDA between 2005 and 2009.”

The FDA took regulatory action against manufacturers Baxter and Hospira in 2012, but this has led to the use of unfamiliar brands, ECRI reports, which has only confused matters, leading to illogically labeled buttons and difficult interfaces.

And clocking in at No. 1 on the ECRI list, “alarm hazards.”

Clark writes, “Device alarms have ‘doubtless saved many lives,’ the report says, but have overwhelmed, or distracted, or desensitized caregivers to their importance, so real alerts go unattended. In April, a sentinel alert from The Joint Commission noted 98 harm-related events, 80 of which resulted in death, and 13 resulting in permanent loss of patient function.”

The fact that this hazard has been a recurring entry on the list year-after-year is disturbing, she notes, and indicates the struggle providers are having in reducing errors prompted by these devices.

So, there you have it: the list of the ECRI Institute’s top 10 technology hazards of 2014. How are you improving on the technological knowledge of your clinician staff? What mistakes and hazards often plague your organization and what initiatives have you enacted to avoid these issues?

-by Pete Fernbaugh

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