Tuesday, November 05, 2013

A top ten list that indicts an industry

Cheryl Clark over at HealthLeaders Media summarizes the annual ECRI report on the top 10 health care technology hazards. It is tempting to think of this as a report on technologies, but let's remember it is actually a report on how people use technologies.

Here's the (drum-roll) list:

1. Alarm hazards
2. Infusion pump medication errors
3. CT radiation exposures in pediatric patients
4. Data integrity failures in EHRs and other health IT systems
5. Occupational radiation hazards in hybrid ORs
6. Inadequate reprocessing of endoscopes and surgical instruments
7. Neglecting change management for network devices and systems
8. Risks to pediatric patients from "adult" technologies
9. Robotic surgery complications due to insufficient training
10. Retained devices and unretrieved fragments

A few comments.  First, with regard to number 6, the only appropriate is "Eeew, that's disgusting!"

Number 9 relates to Intuitive Surgery and its daVinci robot. I wonder if this is the first time that one company accounts for an entire category in the ECRI report. What a milestone that would represent!

What is striking about the others is that there are work-flow remedies that could dramatically reduce these hazards. The fact that they remain on the list is an indictment of the clinical and administrative leaders in many American hospitals.

1 comment:

Anonymous said...

I agree with you about the indictment. My understanding of the endoscope problem is that it is difficult to find methodology that provides adequate sterilization without ruining the function of the fiber optics, but my experience is many years old. Certainly failures have transmitted some serious infections.