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ECRI Institute is providing this abridged version of its 2018 Top 10 list of health technology hazards as a free public service to inform healthcare facilities about important safety issues involving the use of medical devices and systems. Download for free here.
The full report—including detailed problem descriptions and ECRI Institute’s step-by-step recommendations for addressing the hazards—is available to members of certain ECRI Institute programs through their membership web pages. To become a member please contact ECRI’s European Office via our website
The List for 2018
1. Ransomware and Other Cybersecurity Threats to Healthcare Delivery Can Endanger Patients
2. Endoscope Reprocessing Failures Continue to Expose Patients to Infection Risk
3. Mattresses and Covers May Be Infected by Body Fluids and Microbiological Contaminants
4. Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems
5. Improper Cleaning May Cause Device Malfunctions, Equipment Failures, and Potential for Patient Injury
6. Unholstered Electrosurgical Active Electrodes Can Lead to Patient Burns
7. Inadequate Use of Digital Imaging Tools May Lead to Unnecessary Radiation Exposure
8. Workarounds Can Negate the Safety Advantages of Bar-Coded Medication Administration Systems
9. Flaws in Medical Device Networking Can Lead to Delayed or Inappropriate Care
10. Slow Adoption of Safer Enteral Feeding Connectors Leaves Patients at Risk
The Purpose of the List
The safe use of health technology—from beds and stretchers to large, complex imaging systems—requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur. This list will help healthcare facilities do that.
Produced each year by ECRI Institute’s Health Devices Group, the Top 10 Health Technology Hazards list identifies the potential sources of danger that we believe warrant the greatest attention for the coming year. The list does not enumerate the most frequently reported problems or the ones associated with the most severe consequences—although we do consider such information in our analysis. Rather, the list reflects our judgment about which risks should receive priority now.
All the items on our list represent problems that can be avoided or risks that can be minimized through the careful management of technologies. With the additional content provided in the full report, the list serves as a tool that healthcare facilities can use to efficiently and effectively manage the risks.
How Topics Are Selected
This list focuses on what we call generic hazards—problems that result from the risks inherent to the use of certain types or combinations of medical technologies. It does not discuss risks or problems that pertain to specific models or suppliers.
ECRI Institute engineers, scientists, clinicians, and other patient safety analysts nominate topics for consideration based on their own expertise and insight gained through:
Testing medical devices
Observing operations and assessing hospital practices
Reviewing the literature
Speaking with clinicians, clinical engineers, technology managers, purchasing staff, health systems administrators, and device suppliers
Staff also consider the thousands of health-technology-related problem reports that we receive through our Problem Reporting Network and through data that participating facilities share with our patient safety organization, ECRI Institute PSO.
After the topic nomination phase, professionals from ECRI Institute’s many program areas, as well as members of some of our external advisory committees, review these topics and select their top 10. We use this feedback to produce the final list, weighing factors such as the following:
Severity. What is the likelihood that the hazard could cause serious injury or death?
Frequency. How likely is the hazard? Does it occur often?
Breadth. If the hazard occurs, are the consequences likely to spread to affect a great number of people, either within one facility or across many facilities?
Insidiousness. Is the problem difficult to recognize? Could the problem lead to a cascade of downstream errors before it is identified or corrected?
Profile. Is the hazard likely to receive significant publicity? Has it been reported in the media, and is an affected hospital likely to receive negative attention? Has the hazard become a focus of regulatory bodies or accrediting agencies?
Preventability. Can actions be taken now to prevent the problem or at least minimize the risks? Would raising awareness of the hazard help reduce future occurrences?
All the topics we select for the list must, to some degree, be preventable. But any one of the other criteria can, on its own, warrant including a topic on the list. We encourage readers to examine these same factors when judging the criticality of these and other hazards at their own facilities.
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