Top 10 Health Technology Hazards for 2015~2017 (ECRI 2017 十大醫療技術危害 )

(http://bme.freebbs.tw 醫學工程論壇同步發表)

• 今年多了很多的新的主題，跟去年有高達6項差異 (5,6,7,8,9,10)，不過第7項在2014年曾出現過(第5名),今年又重現在第7名。在全文的後面有附各項危害發生的記錄，提供各位醫工好朋友參考。
• 資安方面的議題有1項，但不是IT面而是設備裡的軟體版本差異所造成的隱憂。
• 如果需要全文，可以到下列網址，登錄Email就可以下載全文。如果翻譯有錯，尚請指正。
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ECRI: Top 10 Health Technology Hazards for 2017

	2017	2016	2015
1	Infusion Errors Can Be Deadly If Simple Safety Steps Are Overlooked 若忽視安全操作步驟會使點滴輸液錯誤也有致命性	Inadequate Cleaning of Flexible Endoscopes before Disinfection Can Spread Deadly Pathogens 軟式內視鏡使用前清潔不全會造成致命的病原體散佈	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
2	Inadequate Cleaning of Complex Reusable Instruments Can Lead to Infections 複雜度高且可重複使用儀器清潔不全會導致感染	Missed Alarms Can Have Fatal Consequences 未處理的警報會有致命的後果	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
3	Missed Ventilator Alarms Can Lead to Patient Harm 呼吸器警報疏忽會導致病人傷害	Failure to Effectively Monitor Postoperative Patients for Opioid-Induced Respiratory Depression Can Lead to Brain Injury or Death 疏忽術後病人因鎮痛藥物所引發的呼吸抑制監視，會導致病人腦部損傷或死亡	Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions 點滴幫浦IV管路混用所造的給藥錯誤
4	Undetected Opioid-Induced Respiratory Depression 未察覺鎮痛藥物所引發的呼吸抑制	Inadequate Surveillance of Monitored Patients in a Telemetry Setting May Put Patients at Risk 配帶無線監視器的病人若發射器設定不完全，可能讓病人置於風險當中	Inadequate Reprocessing of Endoscopes and Surgical Instruments 內視鏡設備和手術器械再處理的不足
5	Infection Risks with Heater-Cooler Devices Used in Cardiothoracic Surgery 心胸手術所用冷熱控溫設備感染風險	Insufficient Training of Clinicians on Operating Room Technologies Puts Patients at Increased Risk of Harm 開刀房技術員臨床訓練不足，使病人受傷害的風險增加	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
6	Software Management Gaps Put Patients, and Patient Data, at Risk 設備軟體版本差異造成病人及其資料的風險	Errors Arise When HIT Configurations and Facility Workflow Do Not Support Each Other 醫療資訊技術(Health IT)設定與製造商的工作流程無法互相支援時，造成錯誤漸增。	Patient-Handling Device Use Errors and Device Failures 協助安置病人設備使用錯誤或該設備故障
7	Occupational Radiation Hazards in Hybrid Ors 複合式手術室的職業輻射危害	Unsafe Injection Practices Expose Patients to Infectious Agents 不安全的注射動作造成病患曝露於感染源中	"Dose Creep": Unnoticed Variations in Diagnostic Radiation Exposures 未注意診斷時輻射的變化所產生的劑量問題
8	Automated Dispensing Cabinet Setup and Use Errors May Cause Medication Mishaps 自動包藥機設定及使用錯誤可能造成的給藥事故	Gamma Camera Mechanical Failures Can Lead to Serious Injury or Death 伽瑪照影設備機械結構故障，導致嚴重傷害或死亡	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
9	Surgical Stapler Misuse and Malfunctions 手術釘合器誤用及故障	Failure to Appropriately Operate Intensive Care Ventilators Can Result in Preventable Ventilator-Induced Lung Injuries 加護用呼吸器操作上的疏忽，會造成呼吸器引發的病人肺損傷	Cybersecurity: Insufficient Protections for Medical Devices and Systems 醫療儀器上的資安問題
10	Device Failures Caused by Cleaning Products and Practices 清潔劑及不當的清潔做法可能造成設備失效	Misuse of USB Ports Can Cause Medical Devices to Malfunction 誤用USB埠會造成醫療設備故障	Overwhelmed Recall and Safety-Alert Management Programs 過多的醫儀召修及安全警示管理要求

 By 張韶良(Chang,Shaoliang) slchang88@gmail.com