By ECRI
Providing high-quality patient care requires identifying possible sources of danger or difficulty with health technologies and taking proactive steps to reduce the risk of harm. ECRI produces its annual list of the Top 10 Health Technology Hazards to help in this effort. The report highlights technology management challenges that warrant high-priority attention and provides detailed recommendations for action.
The Challenge Remains
Challenges associated with the COVID-19 public health emergency continue to dominate the health care landscape – a fact that is reflected in the 15th edition of ECRI’s Top 10 Health Technology Hazards list. ECRI’s 2022 report includes several topics that expand on the key theme from last year: the need to progress from crisis mode during the COVID-19 pandemic to building stronger and more resilient processes, leveraging the lessons learned along the way. Other topics on the list address emerging challenges, under-the-radar issues and persistent hazards that require renewed attention.
10 High-Priority Hazards
ECRI identified the following topics as warranting high-priority attention in 2022.
1. Cybersecurity Attacks Can Disrupt Health Care Delivery, Impacting Patient Safety
This year’s No. 1 topic addresses what has become a persistent and critical challenge: the need to safeguard health care operations against near-certain cybersecurity attacks. For health care organizations, cybersecurity incidents can do more than just disrupt business operations – they can disrupt patient care, and thus pose a real threat of physical harm.
Network-connected medical devices and data systems play an essential role in delivering safe and effective patient care. A cybersecurity incident that compromises those devices or systems could lead to the rescheduling of appointments and surgeries, the diversion of emergency vehicles, or the closure of care units or even whole organizations – all of which could put patients at risk.
Cybersecurity incidents have become inevitable, but many can be thwarted or their effects can be minimized if appropriate measures are implemented before an incident, or in response to one. The bottom line? It’s not enough to defend against attacks. Organizations need a plan for maintaining patient care when an incident occurs.
2. Supply Chain Shortfalls Pose Risks to Patient Care
The COVID-19 pandemic created a “perfect storm” for medical device supply chains: a crisis of international scale, with multiple product lines suddenly being in high demand, supported by insufficient supply chains designed around lean inventory models.
Health care supply chains were vulnerable well before the pandemic. But the COVID-19 crisis forced them to the breaking point, leading to the unavailability of products that were needed to treat patients and protect staff. Looking to the future, strategies can be implemented to prevent product shortages and to maintain patient care when traditional supplies become scarce.
3. Damaged Infusion Pumps Can Cause Medication Errors
ECRI continues to receive reports of damaged infusion pumps being used during patient care, a situation that can lead to dangerous medication administration errors. Pump damage can be hard to identify; it may not be visibly apparent or may not trigger an alarm. Too often, this leads to the use of a pump that should have been removed from service. Staff need to be alert to signs of infusion pump damage, and they need to know how to respond if damage is suspected.
4. Inadequate Emergency Stockpiles Could Disrupt Patient Care during a Public Health Emergency
An emergency stockpile helps organizations continue operations when normal equipment inventories or supplies become depleted or when supply chains become disrupted. But if the stockpile is insufficient to meet the needs of the community, health care organizations may be unable to care for the sick and the injured, or to protect their staff. Organizations should work toward the development – and, importantly, the ongoing management – of an emergency stockpile that can better meet future needs.
5. Telehealth Workflow and Human Factors Shortcomings Can Cause Poor Outcomes
Telehealth programs proved their value in recent years, allowing the continued delivery of care at a time when in-person visits weren’t always possible. However, some care providers are now feeling the strain of using telehealth programs that were rapidly implemented during a crisis, without time for full consideration of workflow and human factors. Poor outcomes – both for patients and providers – can result if such factors are not addressed.
6. Failure to Adhere to Syringe Pump Best Practices Can Lead to Dangerous Medication Delivery Errors
Syringe pumps provide highly accurate fluid delivery and consistent flow for small volumes (≤60 mL) of pharmacologic agents. However, misconceptions persist about the practices required to accurately deliver low flows within the confines of the technology’s limitations. Because these pumps are often used in the treatment of critically ill children, infusion errors could have tragic consequences.
7. AI-Based Reconstruction Can Distort Images, Threatening Diagnostic Outcomes
Artificial intelligence is replacing the standard algorithms used to reconstruct images from data obtained during an MRI, CT or other scan. AI can help optimize the quality and speed of reconstruction. But as with any early-stage technology, AI image reconstruction has potential instabilities and limitations. Providers need to be acutely aware of the technology’s limitations – and its applicability to their specific patient population – before implementing AI for imaging applications.
8. Poor Duodenoscope Reprocessing Ergonomics and Workflows Put Health Care Workers and Patients at Risk
The failure to adequately reprocess contaminated duodenoscopes between uses is a well-known hazard, one that has led to the spread of deadly pathogens. Perhaps less well known are the risks of injury to the health care workers who perform this function, and the ways in which ergonomic and workflow factors can compromise reprocessing effectiveness, putting patients at risk. An ECRI survey of health care workers has helped clarify these risks.
9. Disposable Gowns with Insufficient Barrier Protection Put Wearers at Risk
Health care workers and others depend on medical gowns, along with other forms of personal protective equipment (PPE), to provide protection from SARS-CoV-2 and other pathogens. Selecting an appropriate gown for the intended application, however, is not simple: The nomenclature used by suppliers to designate gown types and protection levels is inconsistent, not all gowns are tested to appropriate standards, and manufacturing flaws that compromise protection are occasionally seen.
10. Wi-Fi Dropouts and Dead Zones Can Lead to Patient Care Delays, Injuries and Deaths
Wi-Fi functionality has become essential for transmitting clinical alarms to a nurse’s phone, for accessing the electronic health record (EHR), and for updating infusion pump drug libraries, to name a few workflow and patient safety benefits. But realizing such benefits requires reliable connectivity – and consistently achieving that level of connectivity throughout a facility can be a challenge. What’s more, failing to achieve it can create new avenues for harm, particularly if wirelessly connected devices lose communications at a critical moment.
To Learn More
This article is adapted from ECRI’s Top 10 Health Technology Hazards for 2022. An Executive Brief version of that report is available for complimentary download at www.ecri.org/2022hazards. The full report, accessible to ECRI members, provides detailed steps that organizations can take to prevent adverse incidents. To learn more, contact ECRI at (610) 825-6000, ext. 5891, or by e-mail at clientservices@ecri.org.