By K. Richard Douglas
A January 2015 article in USA Today detailed several incidents of fatal illnesses in Seattle, Pittsburgh, and Chicago related to a superbug bacteria known as Carbapenem-resistant Enterobacteriaceae (CRE). The bacteria is of real concern to medical professionals because it resists even “last defense” antibiotics, according to the story. In each case, the investigation of the source of the deadly bacteria turned out to be a specific type of Endoscope used on a half million patients annually.
Conventional cleaning of these endoscopes proved to be insufficient to remove all bacteria. This problem leads ECRI Institute’s list of the “Top 10 Health Technology Hazards for 2016.” ECRI points out that flexible endoscopes, and duodenoscopes in particular, are constructed in such a way that makes thorough cleaning difficult. The proper reprocessing of these scopes is critical to the well-being of patients. Biologic debris must be removed prior to sterilization or disinfection. The need for this pre-cleaning step is just one area of concern identified by ECRI Institute in this year’s list.
ECRI Institute’s Health Devices Groups says that the list “identifies the potential sources of danger that we believe warrant the greatest attention for the coming year.” ECRI points out that the list does not necessarily reflect the most frequently reported problems, or those with the most severe consequences, but instead those issues demanding the most immediate attention.
Besides the concerns about flexible endoscopes, the list also includes:
- Missed Alarms Can Have Fatal Consequences
- Failure to Effectively Monitor Postoperative Patients for Opioid-Induced Respiratory Depression Can Lead to Brain Injury or Death
- Inadequate Surveillance of Monitored Patients in a Telemetry Setting, May Put Patients at Risk
- Insufficient Training of Clinicians on Operating Room Technologies Puts Patients at Increased Risk of Harm
- Errors Arise When HIT Configurations and Facility Workflow Do Not Support Each Other
- Unsafe Injection Practices Expose Patients to Infectious Agents
- Gamma Camera Mechanical Failures Can Lead to Serious Injury or Death
- Failure to Appropriately Operate Intensive Care Ventilators Can Result in Preventable Ventilator-Induced Lung Injuries
- Misuse of USB Ports Can Cause Medical Devices to Malfunction
“Some of the most obvious resources for addressing these concerns are the hospital IT and biomed/clinical engineering departments. If the concerns and steps listed previously are going to be addressed and utilized, these two departments are going to need a good working relationship.”
The ECRI Institute considers several criteria when forming its list. Those criteria include severity, frequency, breadth, insidiousness, profile (is it publicly known) and preventability. Nominations for the list come from ECRI Institute’s own engineers, scientists, clinicians and other patient safety analysts.
These experts base part of their nominations from investigating incidents, testing medical devices, speaking with other health care professionals, observing operations, assessing hospital practices and reviewing the literature, according to ECRI.
There should be a preventable element to any item that makes it on the list. ECRI also says that the absence of a topic from a previous year should not be perceived as any indication that it is a hazard that no longer deserves attention.