Top 10 Health Technology Hazards in Hospitals

The annual list of health technology hazards from the ECRI Institute identifies the potential sources of danger that warrant the greatest attention for hospitals in the coming year. Eight of the top 10 hazards for 2016 are new to the list.

Contaminated flexible endoscopes is No. 1 on the annual list of Top 10 Health Technology Hazards that hospitals and other providers could confront in the coming year, according to the ECRI Institute.

"Clinical alarms has been at the top for the last four years consecutively. This year it got bumped down to No. 2," says Rob Schluth, senior project officer in the health devices group at ECRI, an independent nonprofit group with a focus on improving patient care.

"I wouldn't say that is because alarm hazard isn't critically important. It certainly is, but it's gotten a lot of attention over the years. The Joint Commission's National Safety Goals has helped create a lot of movement. We are aware of a lot of healthcare facilities that have done a lot of good work trying to address that hazard."

Schluth says improper flexible endoscope reprocessing "bubbled up to the top" with the scores of consultants and analysts at ECRI who composed the 2016 predictor.

"In 2014 and 15 there was a fair amount of press about CRE [Carbapenem-resistant Enterobacteriaceae] infections as a result of endoscopes that weren't properly disinfected between uses," he says. "In addition, ECRI Institute for the past several years has done a number of investigations at healthcare facilities where things could have been handled better. It's a process problem in a lot of cases. If you are doing things incorrectly consistently you could end up affecting a lot of patients. That, coupled with the press the CRE was receiving all helped add to bumping that topic to the top of the list."

ECRI's Top 10 Health Technology Hazards list identifies the potential sources of danger that warrant the greatest attention for the coming year. Schluth says the list reflects ECRI staff's judgment about the risks that should receive priority consideration.

"It's a judgment process. It's not a mathematical process" that involves about 100 analysts, says Schluth. "We ask them to nominate topics. What are they seeing? What are they reading about? What are people reporting to them? And, from what they know, what do they think are worthwhile topics for this list?"

Forward-Looking
The analysts weight their predictions by considering factors such as the severity, frequency, breadth, and preventability of the hazard.

"Some people will stumble on 'isn't it the most number of reports you get?' but one of the purposes for this list is not to tell a history of what happened in the past. It's to help predict what you need to worry about next year," Schluth says. "In doing that you can't rely on the numbers of reports. You have to use the judgment that you've gotten based on testing medical devices, which the people in this group do, and investigating incidents and reading the literature and that kind of thing."

Eight of the top 10 hazards for 2016 are new to the list. "Some of those are related to topics we have covered in the past. There may be different angles. There are certainly persistent issues out there," Schluth says. "We've been doing this list about nine years and clinical alarms has been either No. 1 or No. 2 every year. That in particular is a very complex issue for healthcare facilities to get their arms around."

"With every year we toss out the last year's list and start from scratch. The fact that we do that makes it even more interesting that some of the same topics still get covered," Schluth says. "A lot of times these are complex problems, difficult to correct. There may be new information that comes out each year that we want to share with people to help them make better progress toward addressing the issue."

One new item on this year's list includes a warning on the misuse of USB ports on medical devices. "That was an interesting suggestion. Certainly it wasn't anything that had occurred to me, but that is the type of issue that you see happening more frequently as you go forward as information and medical devices merge," Schluth says.

"USB ports are on these medical devices so that information can be shared back and forth. It's almost a consumer electronics things, but for a medical device, if someone plugs in a smartphone to recharge it at the USB port, there have been reports of that causing problems with the software of the medical device. Things you wouldn't think were an issue with new technologies or new uses for technology can cause problems, especially in a software driven device."