2018年10月3日 星期三

ECRI: Top 10 Health Technology Hazards for 2019

(http://bme.freebbs.tw 醫學工程論壇 同步發表) 

今年的ECRI 醫療科技危害Top10中,IT的議題雖僅1但位居榜首可見IT在醫療儀器的影響仍持續受到影響及關注另有6(2,3,4,5,6,7)是關係到使用者操作的問題同時也有二項(4,7)是持續很多年來的警報議題。值得注意的是清同時因為操作性的問題在本年佔了2特別是在清劑的使用及挑選可能值得醫工好朋友要特別提供些意見給管理及護理單位。
今年的特別處是人為因素比例很高,所以不只SOP的訂定或重新確認,我的看法是,這麼多年來的警訊,教育訓練及SOP應該都已經做過了,實務上的稽核才是是重點,以免都流於形式。



2019
2018
2017
1
Hackers Can Exploit Remote Access to Systems, Disrupting Healthcare Operations
駭客可以利用遠端存取系統方式干援或破醫療系統
Ransomware and Other Cybersecurity Threats to Healthcare Delivery Can Endanger Patients (IT)
勒索軟和其他威脅醫療保健服務網絡安全,可能會危及患者安全
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
2
“Clean” Mattresses Can Ooze Body Fluids onto Patients
不當可能讓病患身體接觸到到液體的滲
Endoscope Reprocessing Failures Continue to Expose Patients to Infection Risk
鏡再處理失敗會持續使患者感染風險
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
3
Retained Sponges Persist as a Surgical Complication Despite Manual Counts
人工計數收回手術使用過的海棉不當仍是手術併發症的因素之一
Mattresses and Covers May Be Infected by Body Fluids and Microbiological Contaminants(感控問題)
床墊和床罩可能會病人體液和微生物污染所引發的感染問題
Missed Ventilator Alarms Can Lead to Patient Harm

呼吸器警報疏忽會導致病人傷害
4
Improperly Set Ventilator Alarms Put Patients at Risk for Hypoxic Brain Injury or Death
呼吸機警報設置不正確使患者面臨缺氧性腦損傷或死亡的風險
Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems
設定失當的警報轉發通知系統可能導致錯誤或遺漏的警報(使用者操作因素)
Undetected Opioid-Induced Respiratory Depression

未察覺鎮痛藥物所引發的呼吸抑制
5
Mishandling Flexible Endoscopes after Disinfection Can Lead to Patient Infections
消毒後處置不當,可能導致患者感染
Improper Cleaning May Cause Device Malfunctions, Equipment Failures, and Potential for Patient Injury
適當的清潔程序可能導致設備故障,失效和患者受傷(使用者操作因素)
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
6
Confusing Dose Rate with Flow Rate Can Lead to Infusion Pump Medication Errors
劑量率與流速設定若觀念混淆會導致輸液泵藥物誤差
Unholstered Electrosurgical Active Electrodes Can Lead to Patient Burns
手術使用電燒時電燒筆置放未適當套住絕緣,可能因誤觸開關,導致患者灼傷
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
7
Improper Customization of Physiologic Monitor Alarm Settings May Result in Missed Alarms
生理監視器警報設置的不正確定可能導致錯失警報
Inadequate Use of Digital Imaging Tools May Lead to Unnecessary Radiation Exposure
成像工具使用不當可能導致不必要的輻射照射(使用者操作因素)
Occupational Radiation Hazards in Hybrid Ors

複合式手術室的職業輻射危害
8
Injury Risk from Overhead Patient Lift Systems
病人抬舉設備的傷害風險
Workarounds Can Negate the Safety Advantages of Bar-Coded Medication Administration Systems(使用者操作因素)
條碼藥物管理系統的安全優勢可能因現場過度變通使用方法造成安全性下降。
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
9
Cleaning Fluid Seeping into Electrical Components Can Lead to Equipment Damage and Fires
清潔液滲入電氣元件可能導致設備損壞和火災
Flaws in Medical Device Networking Can Lead to Delayed or Inappropriate Care
醫療設備網的缺陷可能會導致延遲或不當護理 (IT)
Surgical Stapler Misuse and Malfunctions

手術釘合器誤用及故障
10
Flawed Battery Charging Systems and Practices Can Affect Device Operation
使用有缺陷的電池充電系統可能會影響設備操作
Slow Adoption of Safer Enteral Feeding Connectors Leaves Patients at Risk(器材因素)
未使用專用的腸內餵食連接器使患者面臨誤接輸液的風險
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
By 張韶良(Chang,Shaoliang)2018.10.03 slchang88@gmail.com



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