ECRI Announces Top 10 Healthcare Technology Hazards

Cheryl Clark, for HealthLeaders Media , November 5, 2013

9. Robotic surgery complications due to insufficient training
Also debuting on the list is the rise in reports of complications as a result of surgery assisted by robots, namely "Intuitive Surgical's da Vinci Surgical System," the "only multipurpose robotic surgery system on the market."

The report suggests that robotic systems "are being used for a greater number of cases or for additional kinds of procedures without adequate consideration of the surgical team's proficiency."

The report says that initial training by the device supplier "is intended to help users become familiar with the system and the supplier suggests ways surgeons can get specific training.

"However, the supplier's program does not teach trainees how to perform specific surgical procedures. Thus it is up to the hospital to verify that surgical staff have the necessary procedure-specific skills."

The report advises hospitals to make sure that surgeons maintain competency with sufficient caseload "so that the surgical teams' skills remain sharp."

10. Retained devices and unretrieved fragments
This hazard is back on the list after a three-year hiatus. ECRI was prompted to bring it back by information gleaned from these sources:

  • A 2012 Pennsylvania patient safety reporting system found 452 retained surgical items in 2011, one third of which caused patient harm.
  • A recent analysis of 9,744 malpractice settlements and judgments between 1990 and 2010 found nearly half involved a retention of a surgical item.
  • A recent Sentinel Event alert from the Joint Commission noted 772 such incidents reported to the Sentinel Event Database from 2005 to 2012, including 16 resulting in patient death.
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