Inadequate device cleaning tops alarm fatigue on ECRI health hazards list

Medical devices and systems that could pose major risks for hospitals, health systems and patients in 2016 include inadequate cleaning of endoscopes, missed clinical alarms, and insufficient support of HIT configurations and workflow.

The list of top 10 hazardous technologies was released by the ECRI Institute today as a way "to help hospitals prioritize technology safety efforts that warrant their attention and to reduce risks to patients," according to an announcement.

No. 1 on the list is a failure to clean and disinfect clinical instruments, including endoscopes.The hazard bumped alarm fatigue--which held the No. 1 spot for four years running--to the No. 2 position.

Earlier this year it was revealed that improperly-cleaned medical scopes were linked to deadly superbugs in hospital settings. In addition, contaminated medical equipment poses a similar risk in outpatient settings and doctors' offices, according to a new advisory from the Centers for Disease Control and Prevention and the U.S. Food & Drug Administration.

The report's authors say alarm fatigue is still a major problem and could lead to serious patient injury. Risks occur when a medical device doesn't recognize an alarm condition, when a condition is detected but there's inadequate communication to staff members or when clinical staff does not appropriately address the condition.

"Addressing clinical alarm hazards in all their forms requires a comprehensive alarm management program that includes stakeholders from throughout the organization," the report says.

Other hazards on the list include:

  • Failure to monitor post-operative patients for opioid-induced respiratory depression
  • Inadequate surveillance of monitored patients in a telemetry setting
  • Insufficient training for technologies in operating rooms
  • Misuse of USB ports, which can make medical devices malfunction

"With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked," Anthony Montagnolo, chief operating officer of the ECRI Institute, said in the announcement. "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."

To learn more:
- read the announcement 
- get the report

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