Inadequate Reprocessing of Surgical Instruments on ECRI's Annual Health Technology Hazards List


For the third year in a row, clinical alarms is No. 1 on the list of ECRI Institutes Top 10 Health Technology Hazards, beating out infusion pump medication errors for the lead spot. Inadequate reprocessing of scopes and surgical instruments is No. 6 on the list.

Excessive numbers of alarmsparticularly alarms for conditions that arent clinically significant or that could be prevented from occurring in the first placecan lead to alarm fatigue, and ultimately patient harm, according to ECRIs article. However, it is not only fatigue that poses risks, but the potential for alarms not to sound when a patient is in need, the institute notes.

Clinicians and healthcare facilities are paying closer attention to alarm systems management as a result of The Joint Commissions (TJC) National Patient Safety Goal (NPSG) for 2014. To help facilities understand and prepare for the NPSG on clinical alarms, the AAMI Foundations Healthcare Technology Safety Institute (HTSI) is hosting a free  webinar series in coordination with a number of interested parties. The next webinar is scheduled for Dec. 3. For more information, click HERE.

ECRIs list also names several new topics for 2014, including hazards related to radiation exposure in hybrid operating rooms (OR) and robotic surgery complications as a result of insufficient training.

Hybrid ORs make the list because of occupational hazards posed by their use, according to the article. Clinicians working in the hybrid OR may not have the knowledge about the precautions they need to take to prevent unnecessary exposure to ionizing radiation.

If a hybrid OR is to be implemented, healthcare facilities must have in place a radiation protection program that provides staff with the knowledge and technology they need to minimize occupational radiation exposures in this unique environment, the article says.

Robot-assisted surgery makes ECRIs list after media reports of adverse events as a result of clinicians using this technique. ECRI acknowledges that such reports do not rise to the level of evidence-based research studies, but they do draw attention to the critical need for appropriate training, detailed credentialing, and ongoing surgical team competency assessments to minimize patient risk. 

The full ECRI list for 2014 is:
1. Alarm hazards
2. Infusion pump medication errors
3. CT radiation exposures in pediatric patients
4. Data integrity failures in EHRs and other health IT systems
5. Occupational radiation hazards in hybrid ORs
6. Inadequate reprocessing of endoscopes and surgical instruments
7. Neglecting change management for networked devices and systems
8. Risks to pediatric patients from adult technologies
9. Robotic surgery complications due to insufficient training
10. Retained devices and unretrieved fragments

For two years, AAMI has compiled and released its own list of the top medical device challenges. That list is the result of a survey sent out to healthcare technology management professionals working in hospitals. In 2013, alarm management came in at the No. 5 spot on the AAMI list. Managing devices and systems on the IT network was named as the top challenge. To read more about the AAMI list, click HERE.

Source: AAMI


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