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 of cancer later in life.”
Some suggestions: The report suggests that health care providers take the following actions: use safer diagnostic options, when possible, such as X-rays, MRIs, or ultrasounds; avoid repeat scanning; and use a dose that is “as low as reasonably achievable.”
Occupational radiation hazards in hybrid ORs (#5)
The risk: Hybrid ORs, which bring advanced imaging capabilities into the surgical environment, are a growing trend. However, with these angiography systems comes exposure to radiation—a risk to both patients and OR staff.
Some suggestions: According to the report, a radiation protection program is a must. The program should include training for staff, who may not have experience with imaging technology; the use of shielding with lead aprons or other lead barriers; and monitoring of radiation levels.
Robotic surgery complications due to insufficient training (#9)
The risk: In the last 10 years, there has been an increase in surgery assisted with the use of robotic arms. There has also been an increase in media reports criticizing this technology, or rather the surgical team’s proficiency in using it.
Some suggestions: The report suggests that hospitals ensure that surgeons and staff complete a “multifaceted, detailed training program to develop proficiency and expertise with a multipurpose robotic surgery system.” The hospitals should also make sure that these teams maintain their competency with the system over time.
Retained devices and unretrieved fragments (#10)
The risk: Not seen on the list since 2010, this item was included after a number of recent reports of unintended retention of surgical items in patients (which can lead to risks such as infection, tissue damage, and the need for additional surgery).
Some suggestions: The report suggests visually inspecting devices before and after use and implementing surgical count procedures.
Other hazards that made the list for 2014 include data integrity failures in electronic health records and other health IT systems and neglecting change management for networked devices and systems. Click here to request a copy of the full report.—Amy M. Collins, editor