Providing safe and effective patient care requires identifying sources of danger or difficulty with health technologies and taking steps to reduce the risk. ECRI produces its annual Top 10 Health Technology Hazards report to help in this effort.
The full report, accessible to ECRI members at https://ly.ecri.org/2025Top10Hazards, probes the system issues that contribute to each hazard and provides detailed recommendations to prevent harms. For non-members, an Executive Brief is available for complimentary download at https://ly.ecri.org/2025hazards.
ECRI identified the following topics as warranting high-priority attention in 2025.
1. Risks with AI-Enabled Health Technologies
Artificial intelligence offers the promise of increasing the efficiency and precision of medical diagnoses, treatments, and services; but improvements are not guaranteed. Placing too much trust in the AI model may lead to inappropriate patient care decisions.
The potential for preventable harm exists if, for example, biases are present in the data used to train the AI model, if the model is not well matched to the target patient population, or if the model’s performance is not monitored over time. Further, AI solutions can yield disappointing results if organizations have unrealistic expectations, fail to define goals, provide insufficient governance and oversight, or don’t adequately prepare their data for use by the AI application.
2. Unmet Technology Support Needs for Home Care Patients
The safe and effective use of complex medical devices in the home setting requires more than just user training for patients and family members, it requires adherence to sound technology management practices. These include assessing device usability in the context of the user’s abilities, mitigating any physical or structural limitations in the intended area of use, and supplying the appropriate accessories, as well as providing sufficient training for proper device operation and maintenance.
Inattention to such practices can lead to events and errors going undetected, readings from the device being misinterpreted, or care delays and other harm from unresolved device malfunctions.
3. Vulnerable Technology Vendors and Cybersecurity Threats
The practice of health care increasingly depends on the availability and performance of systems hosted by external (i.e., third-party) vendors. While there are many benefits to the use of scheduling and billing services, electronic health records (EHRs), and other services provided by third-party vendors, the arrangement also involves risks that must be managed.
Past instances of unauthorized access, disruption to services, or other adverse cybersecurity events that incapacitated or degraded operations at the vendor have had downstream effects for health care providers. Incidents have left providers without access to critical services, reliable data, or effective communications channels with their partnering care providers. Such eventualities put patients in harm’s way by delaying, degrading or preventing care.
4. Substandard or Fraudulent Medical Devices and Supplies
Large-scale instances of substandard or fraudulent (e.g., counterfeit) products reaching the U.S. market have become startlingly common. Patients or staff can be harmed if medical devices or supplies (e.g., syringes, isolation gowns) do not function as intended.
Substandard or fraudulent devices may be more susceptible to failure or malfunction, leading to misdiagnoses or injuries. Additionally, the disruptions and recalls that these products cause can stress the supply chain, leading to product shortages; and the need for corrective actions can cost time and money, as health care organizations must review inventories for affected items.
5. Fire Risk in Areas Where Supplemental Oxygen Is in Use
In the acute care setting, OR staff are typically well aware of fire risks during surgery. Outside the OR, however, ECRI’s investigations suggest that increased attention is needed to prevent fires in areas where supplemental oxygen is being delivered.
The three elements needed for a fire – an oxidizer, a fuel and an ignition source – can be present wherever oxygen is delivered. Ignition sources can range from the obvious (e.g., an electrosurgical unit pencil) to the unsuspected, such as a defibrillator, heated humidifier, fiberoptic light source or damaged electrical cord.
6. Dangerously Low Default Alarm Limits on Anesthesia Units
Certain anesthesia units can be configured such that the default alarm limits (those active whenever a new surgical case is started) will be set to zero or a similarly unsafe lower limit. In effect, this disables the alarm at the start of the case. ECRI has investigated numerous incidents in which inappropriate default alarm limits caused dangerous conditions to go undetected, in some cases leading to brain damage or death.
While anesthesia providers can set lower alarm limits to zero when needed during a procedure, ECRI recommends against configuring the unit such that the lower limit defaults to zero (or some other unsafe lower limit).
7. Mishandled Temporary Holds on Medication Orders
The need to suspend (or hold) the administration of a drug based on clinical circumstances is a common occurrence during patient care. Yet errors can arise if organizations lack carefully vetted workflows for documenting hold order parameters in the EHR.
The Institute for Safe Medication Practices has found that errors associated with hold orders often can be attributed to uncertainty about what a hold order means, how the order should be communicated or what process should be followed. Failure to hold a medication when indicated, or neglecting to either restart or discontinue a held medication as circumstances require, can lead to patient harm.
8. Infection Risks and Tripping Hazards from Poorly Managed Infusion Lines
The improper management of infusion lines and connectors creates multiple opportunities for harm. Healthcare-associated infections are one example. Infections can result if care providers don’t clean and disinfect an infusion line connector before access, if they touch the insertion site or tubing with contaminated gloves, or if they don’t follow sterile technique when preparing the infusate.
Another circumstance that can lead to harm is if infusion lines are allowed to dwell on the floor. This creates a tripping hazard that can lead to patient or staff injuries from a fall, as well as patient harm if the infusion line becomes dislodged.
9. Skin Injuries from Medical Adhesive Products
Medical adhesive products are used for a variety of applications, such as dressing wounds, securing IV lines or attaching ECG electrodes. But not all adhesives are the same, and not all patients will respond similarly to an adhesive product.
Inappropriate choices or errors in use can lead to skin tears, blisters, adverse reactions like contact dermatitis, or other forms of injury. While most skin injuries resolve within a few days, they nevertheless cause unnecessary discomfort and pain. Additionally, they can leave patients susceptible to infection, which can lead to more severe consequences.
10. Incomplete Investigations of Infusion System Incidents
With so many patients receiving infusion therapy, adverse events associated with the use of infusion pumps are not unusual. Organizations that lack the expertise or resources to conduct a thorough investigation of such incidents will be poorly positioned to prevent future ones.
Of concern is that investigations involving infusion systems can be particularly challenging due to the variety of potential contributing factors. Issues related to the pump hardware and software, the IV administration set and other accessories, and the actions of the user all must be examined. Additionally, staff must know what to do (and what not to do) to facilitate an investigation.
