- Infusion errors top ECRI Institute’s new list of the most dangerous and largely preventable safety hazards related to health technology for 2017.
- The list of top ten hazards includes infection risks associated with heater-cooler devices and opioid monitoring challenges.
- ECRI compiles the list on an annual basis to point out potential safety issues that warrant attention in the coming year.
While newer infusion pumps are designed to reduce the risk of errors, they can’t eliminate all potential errors, ECRI says. Sometimes the safety mechanisms themselves fail, the institute adds. That can lead to uncontrolled flow of medication, putting the patient’s health and life at risk.
Yet many infusion errors can be prevented by simply looking for signs of physical damage to the pump’s components, using the roller clamp on IV tubing, and checking the drip chamber for improper flow of medication, ECRI says.
The second hazard on the list is inadequate cleaning of duodenoscopes and other complex, reusable instruments.
Concerns about “superbug” infections linked to duodenoscopes first arose in 2014, and attention quickly focused on design characteristics that made cleaning difficult. The FDA responded by requiring label updates with warnings and more stringent cleaning instructions.
Rounding out the list are:
- Missed ventilator alarms;
- Undetected opioid-induced respiratory depression;
- Infection risks with heater-cooler devices used in cardiothoracic surgery;
- Software management gaps, which put patients and patient data at risk;
- Occupational radiation hazards in hybrid operating rooms;
- Automated dispensing cabinet setup and use errors;
- Surgical stapler misuse and malfunctions;
- Device failures caused by cleaning products and practices.
ECRI based the ranking on the severity of infection risks and the problem’s persistence. Issues are selected based on factors such as severity, frequency, scope of consequences and preventability.
The report also includes a section listing resources to address each of the ten hazards.