Additionally, "bone and tissue were observed in an instrument tray for joint replacement surgery," and "blood was observed on the instrument bin inside a surgical case cart before a procedure was started."
The report said inadequate processing of instruments "can damage an organization's reputation, reduce patient satisfaction, prompt review by accrediting agencies, and lead to citations and fines from regulatory bodies or lawsuits form patients."
7. Neglecting change management for network devices and systems
Also on the list for the first time, the report said, is the "underappreciated consequence" of that updates, upgrades or modifications made to one device or system have on other connected devices or systems.
For example, a Windows 7 upgrade at one hospital "caused the loss of remote-display capability for its fetal monitoring devices," which were incompatible. Also, an EHR software upgrade changed radiology reports, "causing fields for the date and time of the study to drop from the legal record.
The report recommends that "when making changes to interfaced systems, closely monitor the systems after the change is made to ensure their safe and effective performance."
8. Risks to pediatric patients from "adult" technologies
The report readdresses this problem, which was introduced as a top 10 hazard last year, saying many hospital systems are not configured for children.
An EHR system, for example, "may not facilitate the recording and review of important pediatric-specific data, such as vaccinations, or may not allow both height and weight to be viewed on the same screen, which in turn can contribute to vital information being overlooked."
Even a scale can generate information that results in harm, for example when a "mix-up involving the use of pounds versus kilograms to record weight contributed to the death of an infant."
In another incident, a toddler's weight was recorded at 25 lb. but was mistakenly recorded in the EHR as 25 kg., which led to a dose calculation twice what the child should get. The mother caught the error before the child experienced adverse effects.