2Alarm Hazards Lead the List
Ventilators, infusion pumps and many other devices generate clinical alarms to help caregivers keep patients safe, but excessive numbers of alarms can lead to fatigue, and patients could be put at risk if an alarm does not activate when it should. Alarms can also distract caregivers from paying attention to more important patient care activities.
3Infusion Pump Medication Errors Place Second
Although invaluable, these devices also represent a large technology management burden, as a hospital may have hundreds or even thousands of these devices in its inventory, and device failures—or failures to use the devices properly—are not uncommon and can cause significant patient harm, the report noted. Infusion pump integration—that is, connecting the servers for the infusion pumps with other information systems—can provide additional protections.
4CT Radiation Exposures a Concern for Pediatric Patients
CT practices that can place children needlessly at risk include the inappropriate use of any technology that uses ionizing radiation, as well as the failure to properly control the radiation dose during such procedures. The report said efforts should be made to minimize a child’s exposure to high doses of ionizing radiation.
5EHRs Can Be Helpful or Harmful for Patients
6Occupational Radiation Hazards Could Impact Hybrid ORs
7Inadequate Reprocessing of Endoscopes and Surgical Instruments
The report warned that successful reprocessing of any device requires consistent adherence to a multistep procedure. Failure to properly perform any step, including some necessary manual tasks, could compromise the integrity of the process and lead to significant patient harm. Staff should be trained in these protocols, and they need adequate space, equipment and instructional materials.
8Neglect of Change Management for Networked Devices and Systems
One underappreciated consequence of system interoperability is that updates, upgrades or modifications made to one device or system can have unintended effects on other connected devices or systems, like a facilitywide PC operating system upgrade that causes the loss of remote-display capability for a hospital’s fetal monitoring device.
9Risks to Pediatric Patients From ‘Adult’ Technologies
10Robotic Surgery Complications Due to Insufficient Training
11Retained Devices and Unretrieved Fragments
Last appearing on the list in 2010, a string of incidents prompted the organization to include retained surgical items (RSIs) as a 2014 top risk. Risks to patients can include prolonged or additional surgery, as would occur when an RSI is discovered and its removal is deemed appropriate, or future complications, some potentially serious, as could occur when an RSI leads to infection or causes damage to the surrounding tissue.