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, and 2015.) Here is a brief overview of other hazards that made the cut.

Failure to effectively monitor postop patients for opioid-induced respiratory depression (#3)

The risk: Hospitalized patients receiving postoperative opioids such as morphine, hydromorphone, or fentanyl are at risk for drug-induced respiratory depression, which can lead to brain injury or death.

Recommendation: The report suggests that a facility’s leadership should implement the relevant recommendations from the Anesthesia Patient Safety Foundation and the Joint Commission.

Inadequate surveillance of monitored patients in a telemetry setting (#4)

The risk: Inadequate surveillance of telemetry patients can lead to unrecognized critical events and patient harm. Contributors to this problem include the assumption that monitoring systems reliably detect all potentially lethal arrhythmias; the trend toward using telemetry with sicker patients; and the display of patient monitoring information only at the central station, where events may be missed if staff are not present or if they are distracted.

Recommendation: The report calls for educating personnel about the limitations of monitoring technology and the factors that could lead to missed events, as well as implementing measures to improve patient surveillance.

Unsafe injection practices (#7)

The risk: Unsafe injection practices, such as reusing a needle or syringe that has been used to administer medication, sharing an insulin pen among patients, and using a single-dose medication vial for multiple patients, can lead to the transmission of blood borne viruses, the spread of bacterial infections, and potential exposures that require notifying large numbers of patients about the threat to their health.

Recommendation: Solutions to this problem, according to the report, involve action by frontline health care workers, hospital leadership, outpatient clinics, and skilled nursing facilities, and by patients themselves.

Gamma camera mechanical failures (#8)

The risk: Gamma cameras are made up of heavy, moving components that can cause great harm if they rotate into or fall onto a patient or staff member.

Recommendations: Facilities should advise staff not to leave patients unattended in the gamma camera scan room, according to the report. They should also maintain, service, and inspect gamma cameras, and verify that all current recalls and safety notices have been acted on.

Misuse of USB Ports

The risk: Plugging unauthorized devices or accessories into USB ports on medical devices can cause the medical devices to malfunction.

Recommendation: The report states that facilities need to develop and implement a policy on the appropriate use of USB ports on medical devices.

To download the full summary of the report, visit: More detailed descriptions of the hazards, along with comprehensive guidance and exclusive ECRI Institute recommendations, are available to ECRI Institute members. Non-members can purchase the 2016 Top 10 Health Technology Hazards Solutions Kit for online access to those same resources for each hazard.—Amy M. Collins, managing editor


2016-11-21T13:01:33+00:00 January 14th, 2016|Nursing|3 Comments
Managing editor, American Journal of Nursing


  1. Susan January 15, 2016 at 2:25 pm

    Thank you! I am flattered!

  2. Jacob Molyneux January 15, 2016 at 10:25 am

    Hi Susan,
    Just wanted to let you know that I’m going to add your blog to our nursing blogs list, now that I know it exists! Looks promising. Thanks for commenting here!
    Jacob M., AJN senior editor/social media guy

  3. Susan January 14, 2016 at 10:04 pm

    I did a literature review and short article on CRE in the Endoscopy setting for OR Nurse 2015 magazine – the statistics about the mortality of anyone infected with CRE in the blood is awful! Thank you for reiterating the importance of cleaning duodenoscopes.

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