2013 Top 10 Health Technology Hazards List

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2013 Top 10Health Technology Hazards List

2011~2013歷年比較表

	2013	2012	2011
1	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	Radiation Overdose and Other Dose Errors during Radiation Therapy 放射治療的輻射劑量過量和其他劑量錯誤
2	Medication administration errors using infusion pumps 點滴幫浦給藥量錯誤	Exposure hazards from radiation therapy and CT 放射治療及電腦斷層輻射曝露危害	Alarm Hazards 各種不適當警報造成的危害
3	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	Medication administration errors using infusion pumps 點滴幫浦給藥量錯誤	Cross-Contamination from Flexible Endoscopes 軟式內視鏡的交叉污染
4	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	Cross-contamination from flexible endoscopes 軟式內視鏡的交叉污染	The High Radiation Dose of CT Scans 電腦斷層的高輻射劑量
5	Interoperability failures with medical devices and health  IT systems 醫儀與資訊系統連線管理疏忽	Inattention to change management for medical device connectivity 醫儀與資訊系統連線管理疏忽	Data Loss, System Incompatibilities, and Other Health IT Complications 電腦設備與系統的異常
6	Air embolism hazards 空氣栓塞危害	Enteral feeding misconnections 餵食管的錯誤連接	Luer Misconnections 接頭誤接
7	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	Surgical fires 手術室火災	Oversedation during Use of PCA Infusion Pumps 自控式止痛器導致的過度鎮靜
8	Inadequate reprocessing of endoscopic devices and surgical instruments 軟式內視鏡及手術器械的交叉污染	Needlesticks and other sharps injuries 針頭或其他銳器傷害	Needlesticks and Other Sharps Injuries 針扎與其他銳器造成的傷害
9	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	Anesthesia hazards due to incomplete pre-use inspection 檢查疏失造成的麻醉意外	Surgical Fires 手術室火災
10	Surgical Fires 手術室火災	Poor usability of home-use medical devices 家用醫療器材可用性不佳造成的意外	Defibrillator Failures in Emergency Resuscitation Attempts 除顫器於急救復甦時失效

What’s New on This Year’s List?

In the current healthcare environment, the interplay between complexity and either effectiveness or the potential for harm is perhaps most evident in the realm of healthcare information technology, or health IT. Thus, it shouldn’t be surprising that 3 of the 10 topics on this year’s list are associated with the still-maturing health IT field.

Health IT encompasses information systems such as electronic health records (EHRs), the hardware and software that support human interactions with such systems (e.g., laptops, tablet computers,smartphones), and the interfaces that allow interactions between medical devices and these and other systems.

While many health IT implementations offer great promise for improving patient care, it must be recognized that these complex technologies also can create new paths to failure.


As the Institute of Medicine points out in its 2012 report Health IT and Patient Safety,*However, the report cautions that Designed and applied inappropriately,health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences, for example dosing errors, failure to detect fatal illnesses, and delayed treatment due to poor human–computer interactions or loss of data.


It is widely believed that health IT, when designed, implemented, and used appropriately, can be a positive enabler to transform the way care is delivered.


The complexity of these technologies, their potential to introduce new failure modes, and the possibility that such failures will affect many patients before being noticed—combined with the increased usage that will likely result from the U.S. government's incentivizingthe implementationand meaningful use of effective health IT—leads us to encourage healthcare facilities to pay particular attention to health IT when prioritizing their safety initiatives for 2013.