4. Data integrity failures in EHRs and other health IT systems
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.
"Contributing factors include patient/data association errors, missing data or delayed data delivery, clock synchronization errors, inappropriate use of default values, use of dual workflows (paper and electronic), copying and pasting of older information into a new report, and even basic data-entry errors."
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.
5. Occupational radiation hazards in hybrid ORs
An increasing number of hospitals are moving sophisticated imaging equipment into the operating room in order to conduct angiography even during minimally invasive procedures.
"However, as these angiography systems are introduced into the OR, so too" is the risk of ionizing radiation exposure to healthcare workers who may not have experience working in such settings as do their colleagues in radiology or catheterization labs.
"Knowledge of the risks and the experience in executing precautions may be lacking—a situation that could lead to unnecessary radiation exposures to those clinicians working in a hybrid OR on a daily basis," the report says.
Training, shielding, and monitoring are essential, the report says about this hazard, the first time it has been included on the list. "Radiation monitoring badges are used to keep track of clinician exposure," so doses are not exceeded.
6. Inadequate reprocessing of endoscopes and surgical instruments
On the list for every one of the last five years, problems with disinfection of endoscopes have resulted in transmission of hundreds of infectious-disease causing organisms. But this year, ECRI has added improper sterilization of other surgical devices, such as an arthroscopy shoulder cannula and a broncoscopy scope.