Health Technology Hazards, 2016: Inadequate Disinfection of Flexible Endoscopes Tops ECRI List

hazard/jasleen kaur, via Flickr hazard/jasleen kaur, via Flickr

The ECRI Institute has released its Top 10 Health Technology Hazards for 2016 report, highlighting health technology hazards for health care facilities and nurses to focus on this year.

Although alarm hazards, which topped the list for the past four years, still pose a significant threat, topping the list at number two, a different repeat offender has claimed the number one spot: inadequate cleaning of flexible endoscopes before disinfection.

Proper reprocessing and cleaning of biologic debris and other foreign material from instruments before sterilization is key, according to the report. And flexible endoscopes, especially duodenoscopes, are difficult to clean because of their long, narrow channels. Failure to clean properly can result in the spread of pathogens. The report points to a series of fatal carbapenem-resistant Enterobacteriaceae infections in the last two years to illustrate this particular threat, and recommends that facilities emphasize to their reprocessing staff that inattention to proper cleaning steps can lead to deadly infections.

Some hazards, such as those arising from health information technology (HIT) issues, insufficient training of clinicians in operating room technologies, and failure to appropriately operate intensive care ventilators, have been touched on in previous years. (See our past posts on ECRI top 10 health technology hazards from 2013, 2014, […]

2016-11-21T13:01:33-05:00January 14th, 2016|Nursing|3 Comments
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Addressing Alarm Fatigue in Nursing

by flattop341/via flickr by flattop341/via flickr

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

“Will you please silence that alarm?!” The nurse is on the phone, and can’t reach the screaming cardiac monitor. It’s a normal request, considering that we’re working together in an ICU and the alarm has been ringing for awhile.

But her request for silencing the alarm isn’t issued to me; she’s talking to the unit clerk. Stuck in my patient’s room, I watch as this untrained staff member taps the flashing rectangle on the unit’s central monitor. Without having first been appropriately evaluated, the ringing disappears, along with the words “Multifocal PVCs.”

Later, the same unit clerk absentmindedly turns off a sounding alarm, without encouragement from a nurse. I’m floating today, and although I’ve just met her, I can’t help but ask, “Do you know what that alarm was saying? Was it accurate?”

She is clearly startled by my admonishment, but I persist. “A lot of the alarms around here do seem to be false, but what if this one wasn’t? Do you have the training to know the difference, and to report it?”

If looks could kill, the one that meets my gaze is certainly homicidal, but it’s paired with a grumbled promise to never touch the screen again. So maybe […]

2016-11-21T13:02:55-05:00March 2nd, 2015|Nursing, nursing perspective, Patients|5 Comments
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Health Technology Hazards, 2015: Alarm Issues Still Lead ECRI Top 10

hazard/jasleen kaur, via Flickr hazard/jasleen kaur, via Flickr

It’s a new year, and the ECRI Institute has released its Top 10 Health Technology Hazards for 2015 report, highlighting new health technology hazards (and some older, persistent ones) for health care facilities and nurses to keep in mind.

Alarm hazards still posed the greatest risk, topping the list at number one for the fourth year running. But this year, the report focused on different solutions. Often, according to the report, strategies for reducing alarm hazards focus on alarm fatigue—a hazard nurses have long battled. Now, the report recommends that health care facilities examine alarm configuration policies and practices for completeness and clinical relevance. These practices include:

  • determining which alarms should be enabled.
  • selecting alarm limits to use.
  • establishing the default alarm priority level.
  • setting alarm volumes.

Repeat hazards that made the list included inadequate reprocessing of endoscopes and surgical instruments (#4), robotic surgery complications due to insufficient training (#8), and, in at #2, data integrity issues such as incorrect or missing data in electronic health records and other health IT systems. For an overview of these hazards, see our posts on ECRI top 10 health technology hazards from 2013 and 2014.

And here’s an overview of new hazards that made the cut, along with some of the report’s […]

2016-11-21T13:03:15-05:00January 12th, 2015|digital health, Nursing, Technology|1 Comment
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Health Technology Hazards: ECRI’s Top 10 for 2014

hazard/jasleen kaur, via Flickr hazard/jasleen kaur, via Flickr

It’s that time of year again—the ECRI Institute has released its Top 10 Health Technology Hazards for 2014 report, and with it come new (and old) hazards to keep in mind.

Alarm hazards still posed the greatest risk, topping the list at number one for the third year running. Other repeat hazards included medication administration errors while using smart pumps (in at number two), inadequate reprocessing of endoscopic devices and surgical instruments (number six), and, at number eight, risks to pediatric patients associated with technologies that may have been designed for use in adults (such as radiology, oxygen concentrators, computerized provider order–entry systems, and electronic medical records). For an overview on these, see our posts from 2012 and 2013.

And here’s a snapshot of new hazards that made the cut, along with some of the report’s suggestions on how to prevent them.

Radiation exposures in pediatric patients (#3)

The risk: Although computed tomography (CT) scans are valuable diagnostic tools, they are not without risk, and children, who are more sensitive to the effects of radiation than adults, are more susceptible to its potential negative effects. According to the report, new empirical studies suggest that “diagnostic imaging at a young age can increase a person’s risk […]

2016-11-21T13:05:37-05:00January 15th, 2014|digital health, Nursing, Technology|1 Comment
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Health Technology Hazards: Top 10 for 2012

Advances in health technology can save patients’ lives, but can also cause harm, as the recent Ecri Institute report, Top 10 Technology Hazards for 2012, reminds us. Here’s a snapshot of the hazards nurses should be focusing on, and some suggestions they give on how to prevent them.

1. Alarm hazards
The risk: With nurses being constantly bombarded by bells, it’s easy to see how alarm fatigue can set in, leading to desensitization, nurses being unable to distinguish the urgency level of alarms, and improper alarm adjusting.

Some suggestions: According to the report, a facility should look at the big picture, examining the entire alarm environment when setting up an alarm-management system. Alarm notification and response protocols should be developed to ensure that each alarm will be recognized, that the appropriate caregiver will be notified, and that the alarm will be promptly addressed. Policies should also be established to control alarm silencing, modification, and disabling.

2. Radiation exposure
The risk: High levels of radiation used during radiation therapy can cause serious harm if errors occur, including damage to normal tissue and organs. And despite radiation levels being lower in diagnostic settings, the increasing number of patients undergoing diagnostic radiography may reveal more risks in the future.

Some suggestions: The report suggests that […]

2016-11-21T13:11:03-05:00January 5th, 2012|Nursing|0 Comments
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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