ECRI Institute 2015 Top 10 Health Technology Hazards
2014年已到11月了，ECRI也整理出今年的的TOP10醫療科技危害(2015)，作為明年的病人安全作業參考。
The List for 2015
1. Alarm Hazards: Inadequate Alarm Configuration Policies and Practices
2. Data Integrity: Incorrect or Missing Data in EHRs and Other Health IT Systems
3. Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions
4. Inadequate Reprocessing of Endoscopes and Surgical Instruments
5. Ventilator Disconnections Not Caught because of Mis-set or Missed Alarms
6. Patient-Handling Device Use Errors and Device Failures
7. “Dose Creep”: Unnoticed Variations in Diagnostic Radiation Exposures
8. Robotic Surgery: Complications due to Insufficient Training
9. Cybersecurity: Insufficient Protections for Medical Devices and Systems
10. Overwhelmed Recall and Safety-Alert Management Programs
臨床類的有的7項(警報類的事件仍是蟬聯榜首),
IT類的2項(紅色)，
醫儀管理的1項(藍色)，也是近年來首次提及的。
https://www.ecri.org/Forms/Pages/2015hazards.aspx
以下是整理自2013~2015的比較
因版權問題，不能直接提供文件下載的連結，有興趣的夥伴，可以點選下列網址，簡單登記一下(有星號的部份就可以了)，就可以下載文件。
https://www.ecri.org/Forms/Pages/2015hazards.aspx
以下是整理自2013~2015的比較
2015
|
2014
|
2013
|
|
1
|
Alarm Hazards: Inadequate Alarm Configuration Policies and
Practices
各種不適當警報設定及政策造成的危害
|
Alarm hazards
各種不適當警報造成的危害
|
Alarm hazards
各種不適當警報造成的危害
|
2
|
Data Integrity: Incorrect or Missing Data in EHRs and Other
Health IT Systems
電子健康檔案和其他醫療IT系統的資料整合失敗
|
Infusion pump medication errors
點滴幫浦的給藥錯誤
|
Medication administration errors using infusion pumps
點滴幫浦給藥量錯誤 |
3
|
Mix-Up of IV Lines Leading to Misadministration of Drugs and
Solutions
點滴幫浦IV管路混雜所造的給藥錯誤
|
CT radiation exposures in pediatric patients
在兒科患者的CT輻射暴露
|
Unnecessary radiation exposures and radiation burns during
diagnostic radiology procedures
非必要輻射曝露及檢查過程中輻射灼傷
|
4
|
Inadequate Reprocessing of Endoscopes and Surgical Instruments
內視鏡設備和手術器械再處理的不足
|
Data integrity failures in EHRs and other health IT systems
電子健康檔案和其他醫療IT系統的資料整合失敗
|
Patient/data mismatches in EHRs and other health IT HIT systems
電子病歷及其他健康資訊資料錯誤
|
5
|
Ventilator
Disconnections Not Caught because of Mis-set or Missed Alarms
呼吸器管路不合或忽視警報所造的管路脫落
|
Occupational radiation hazards in hybrid ORs
混合式手術室的職業輻射危害
|
Interoperability
failures with medical devices and health IT systems
醫儀與資訊系統連線管理疏忽
|
6
|
Patient-Handling
Device Use Errors and Device Failures
協助安置病人設備使用錯誤及故障
|
Inadequate reprocessing of endoscopic devices and surgical
instruments
內視鏡設備和手術器械再處理的不足
|
Air embolism hazards
空氣栓塞危害
|
7
|
未注意診斷時輻射的變化所產生的劑量問題
|
Neglecting change management for networked devices and systems
忽略聯網設備和系統的變更管理
|
Inattention to the needs of pediatric patients when using
"adult" techniques
用成人治療技術未注意小兒病患的差別需求
|
8
|
Robotic
Surgery: Complications due to Insufficient Training
由於訓練不足所導致的機器人手術併發症
|
Risks to pediatric patients from "adult"
technologies
使用"成人"技術時導致的兒科患者的風險
|
Inadequate reprocessing of endoscopic devices and
surgical instruments
軟式內視鏡及手術器械的交叉污染
|
9
|
Cybersecurity: Insufficient Protections for Medical Devices
and Systems
醫療儀器上的資安問題
|
Robotic surgery complications due to insufficient training
由於訓練不足所導致的機器人手術併發症
|
Caregiver distractions from smartphones and other
mobile devices
智慧型手機或行動裝置造成醫護人員分心
|
10
|
Overwhelmed
Recall and Safety-Alert Management Programs
過多的醫儀召修及安全警示管理要求
|
Retained Devices and
Un-retrieved Fragments
遺留的物件和無法恢復的碎片
|
Surgical Fires
手術室火災 |
