1. Alarm hazards: In April 2013, the Joint Commission cited 98 alarm-related events over a 31/2 year period, with 80 events resulting in death and 13 in permanent loss of function.
2. Infusion pump medication errors: Infusion devices are the subject of more adverse incident reports to the FDA than any other medical technology. Reports submitted to the FDA from 2005 through 2009 include 710 deaths.
3. CT radiation exposures in pediatric patients: Retrospective studies being published indicate an increased risk of future cancers for children exposed to CT.
4. Data integrity failures in EHRs and other health IT systems: Reports show numerous ways that data integrity can be compromised, resulting in the presence of incomplete, inaccurate or out-of-date information.
5. Occupational radiation hazards in hybrid ORs: While radiology department and cath lab staffs are generally well versed in the risks and safety precautions, clinicians working in less controlled environments may be at greater risk for radiation exposures.
6. Inadequate reprocessing of endoscopes and surgical instruments: Flexible endoscopes, with narrow, hard-to-clean channels, can be particularly challenging devices to decontaminate.
7. Neglecting change management for networked devices and systems: Planned and proactive changes to one device or system have adversely affected other networked medical devices and systems.
8. Risks to pediatric patients from “adult” technologies: Because of their smaller size and ongoing physiological changes, children may suffer adverse effects when subjected to adult-oriented healthcare techniques.
9. Robotic surgery complications due to insufficient training: Pressure to use robot-assisted surgical procedures without adequate consideration of the surgical team's proficiency has contributed to patient complications.
10. Retained devices and unretrieved fragments: A recently published analysis of 9,744 paid malpractice settlements and judgments associated with surgical “never events” from 1990 to 2010 found that, of the four surgical event types studied, nearly half of the incidents involved the retention of a surgical item.
Source: ECRI Institute