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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。

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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	“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	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