Medscape has published a graphic that lists the 12 most dangerous medical technologies. If you or a loved one have to go into the hospital for a procedure anytime soon, it’s well worth a read.
In compiling the list of dangerous technologies, Medscape relies on the non-profit The ECRI Institute of Plymouth Meeting, Pennsylvania which studies issues in patient care. Some of the items listed are well-known while others run don’t receive quite as much attention for their risk factors.
1.) Device alarms. If you’ve visited a patient in a hospital setting or been hospitalized, you recognize the sound of alarms going off frequently. These alarms are designed to alert the staff when there is an issue with a medical device such as a dialysis machine, infusion pump, or ventilators. The problem with this device is that staff can experience what experts call “alarm fatigue”. They hear the alarms all day long and grow so accustomed to the sound that they inadvertently ignore them.
2.) Radiation therapy and CT scans. Inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Adverse events are probably underreported. “There isn’t a good reporting system in place to define what is a reportable event,” says James P. Keller, Jr., ECRI Institute’s Vice President, Health Technology Evaluation and Safety. Hospitals need to maintain adequate staffing levels and quality assurance procedures. For radiation therapy, facilities need to ensure that staff follow and document standard patient treatment procedures, including double-checks and time-outs, and develop standard checklists.
3.) Medication Errors Using Infusion Pumps. Human error such as typing in the wrong information, medication given to the wrong patient, and misreading a doctor’s prescription order are examples of issues with this type of medication dispensation. “One way to avoid errors is to use a dose-error-reduction system,” says Keller. “It has built-in limits, or guardrails. If a nurse enters a dose that exceeds the limit, an alert will occur to catch the error before it can happen.”
4.) Cross-contamination from Flexible Endoscopes. Improper sterilization procedures can lead to life threatening infections. “We learned of a case where a brand of colonoscope changed its design and required independent cleaning of a new channel for it to be fully disinfected,” says Keller. “The hospital didn’t realize that, so it treated patients with endoscopes that weren’t fully disinfected.”
5.) Device updates and new hardware/software issues. Technology, including medical technology is advancing at a rapid pace requiring a hospital’s IT department to constantly evaluate and update processes and procedures.
6.) Feeding Tube Misconnections. The most serious mistake occurs when nutrients intended for the gastrointestinal tract are inadvertently delivered elsewhere, such as the vasculature. This mistake can cause death, usually by embolus or sepsis. The US Food and Drug Administration (FDA) has urged making connectors and adaptors uniform, so that built-in incompatibility will prevent misconnections. Color-coding was also recommended. Making such changes is voluntary, however, and feeding tube misconnections continue.
7.) Surgical fires. There are approximately 600 surgical fires each year in the USA. These can lead to death, disfigurement, and severe infections. Implement a surgical fire prevention program. To minimize the risks of oxygen-enriched atmospheres, implement new clinical recommendations on oxygen delivery. Discontinue the practice of open delivery of 100% oxygen during head, face, neck, and upper chest surgery. Only air should be used for open delivery to the face, if the patient can maintain safe blood oxygen saturation without supplemental oxygen. The surgical team should have a time-out before starting surgery and assess any fire risks.
8.) Needlesticks and Other Sharps Injuries. This is a problem that continues to occur in spite of medical and technological advances. Hospital administrators should review and identify how and when these accidents occur, gather input from staff members, and implement a safety plan
9.) Anesthesia Dangers from Mistakes in Pre-use Inspection. ECRI’s recommendations: Before the day’s first case, staff members should perform an equipment inspection that includes the model-specific, manufacturer-prescribed full check of the anesthesia unit. Before each subsequent case, make sure that the unit is inspected according to the manufacturer’s instructions. Staff members should know who is responsible for performing the check.
10.) Medical Devices Used in the Home. The FDA has identified 3 challenges: caregiver knowledge, environmental unpredictability, and device usability. Many of the devices used in the home are older and have no labeling or instructions for use or maintenance. ECRI’s recommendations: Assess the patient and caregivers before prescribing any medical device, to ensure that everyone involved in the patient’s care can use the technology appropriately.
11.) Defribillator Failure. This is a common occurrence and completely avoidable if the defibrillators are maintained and inspected on a daily basis.
12.) Luer (Tubing and Catheter) Misconnections. Tubing and catheter misconnections can allow gases or liquids to enter the wrong lines, often severely injuring patients, such as when fluid meant for an enteral feeding tube enters an intravenous catheter. These risks increase when 2 functionally dissimilar devices each use Luer connectors. To prevent such mishaps, conduct periodic training of everyone working in patient care. Prohibit use of adapters, which can permit the connection of 2 components that normally wouldn’t mate. Review purchasing policies to allow only products that include misconnection safeguards.
Improvements in medical technology are only beneficial to the extent they are utilized properly and maintained regularly. Failure to do so can lead to catastrophic injuries and death.