Medical technology can prolong life expectancy. However when not proprely handled, complex medical equipment can also increase the risk of medical malpractice.When the staff is not adequately trained or is too busy, medical errors related to technical equipment can occur. Medical malpractice related to technology hazards can seriously injure or kill patients. The ECRI Institute is closely monitoring risks and related medical errors related to new health technology. Every year the patient advocate organization publishes a report of the 10 biggest technology hazards. Here is the 2017 ranking:
- Infusion error
After a nurse or a member of the medical staff installs a new infusion pump for a patient with an IV line, it seems obvious that he or she would check if the medication drips proprely in the tube. Unfortunately, this simple step is often neglected making infusion errors the biggest technology hazard in healthcare. Physical damages to the pump or staff not making appropriate use of the roller clamp on the IV tubing can cause uncontrolled flow of medication to the patient .”IV free flow” is mostly the result of medical malpractice that is easily preventable. It can cause severe harm to patients. Some of them die.
- Inadequate cleaning of medical instruments
Duodenoscopes, endoscopes, canulated drills and arthroscopic shavers are reusable medical instruments that are extremely difficult to proprely clean and sterilize. Inattention to the the cleaning steps can fail to eliminate contamination of the medical instrument. Contamination has the most risk to occur when manual cleaning before disinfection and sterilization is neglected.
- Missed ventilators alarm
Ventilators provide breathing to patients who are unable to physically breath by themselves. Patients have been dying after the medical staff missed their ventilator alarms. Missed alarms is often the result of alarm fatigue. Because so many medical instruments are now equipped with alarms, the medical staff becomes desensitized to them.
- Opioid-Induced Respiratory Depression
Respiratory depression or hypoventilation is a common side effect of opioid drugs. Patients on opioids who are receiving another drug that sedates them or who suffer from sleep apnea are especially at risk of respiratory depression. If not detected hypoventilation can lead to brain damage or death.
- Development of infection related to heater-cooler devices during heart surgery
Patients who undergo heart surgery may develop nontuberculous mycobacteria (NTM) after being contaminated by the heater-cooler device used during the surgery. Some patients who were exposed to contaminated exhaust vents from the system developed life-threatening infections. The CDC and the FDA are still investigating the exact reasons for the development of this infection.
- Software management gaps
Healthcare facilities need to maintain and organize a repository containing easily accessible information on all medical devices software versions. Mismanagement of software updates and alerts can adversely impact patients. It also creates cyber security vulnerability.
- Occupational radiation hazards in hybrid-OR suites
Some operating suites now include built-in x-ray imaging systems for complex OR procedures. Radiologists and OR staff are working next to each other in these hybrid-OR suites. While radiologists are well aware of the danger of exposure to ionizing radiation, OR staff often didn’t receive appropriate radiation protection training. As a result they may develop cancer related to long-term exposure to radiation.
- Medication errors related to Automated Dispensing Cabinets (ADCs)
Automated Dispensing Cabinets are computerized drug storage cabinets designed for hospital staff. When set up proprely they can be very helpful in tracking and dispensing medication. However when not set up proprely, medication drawers may contain the wrong drug or the wrong drug dosage. Controlled substances that should have been in secured drawers may end up in unsecured areas and needed drugs may be missing. Cases of patients severely injured after absorbing the wrong medication or the wrong dosage of medication have been reported in hospital using ADCs.
- Surgical stapler accidents
Thousands of patients are being injured every year by misused or malfunctioning surgical staplers. Injuries include hemorrhages, tissue damages, postoperative bleeding and failed anastomosis. Too often users do not operate the stapler proprely and are confronted with problems such as difficulty in firing, misapplied staples or tissues jammed in the mechanism.
- Medical devices malfunctioning after being cleaned with the wrong product
The material used in some medical devices may be altered when cleaned with inappropriate products. The hospital staff in charge of cleaning the various medical devices need to be proprely trained on how to clean each device. Additionally all necessary cleaning products for each device need to be stored in sufficient quantity and readily available. Some electronic devices may be damaged by improper cleaning agents or practices. As a result the patient using the device may be harmed.
The complete ECRI Institute Report can be downloaded here