The ECRI Institute named the Top 10 Health Technology Hazards for 2016 and the perennial number one spot, typically saved for "safety risks from clinical alarms" was dethroned; the number one top concern is inadequately-cleaned endoscopes.
An endoscope that isn't properly cleaned could lead to a variety of patient complications and issues, including CRE infections which have attracted national media attention over the past two years. The ERCI Institute also conducted studies into endoscope cleaning and disinfection practices and found them a key hazard to avoid.
"Flexible endoscopes in general, and duoendoscopes in particular, are of specific concern because their complex design and long, narrow channels can make effective cleaning difficult," according to the report. "A series of fatal CRE infections that attracted a lot of attention in 2014 and 2015 illustrate this concern: The deaths were associated with the use of duoendoscopes that had not been successfully disinfected between uses."
The list is as follows:
1. Inadequate cleaning of flexible endoscopes before disinfection can spread deadly pathogens
2. Missed alarms can have fatal consequences
3. Failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death
4. Inadequate surveillance of monitored patients in a telemetry setting may put patients at risk
5. Insufficient training of clinicians on operating room technologies puts patients at increased risk of harm
6. Errors arise when HIT configurations and facility workflow do not support each other
7. Unsafe injection practices expose patients to infectious agents
8. Gamma camera mechanical failures can lead to serious injury or death
9. Failure to appropriately operate intensive care ventilators can result in preventable ventilator-induced lung injuries
10. Misuse of USB ports can cause medical devices to malfunction
"With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked," said ECRI Institute COO Anthony Motagnolo. "Based on our experience with independent medical device testing in our laboratory, accident investigations and reported events, we're very aware of serious safety problems that occur."