TOP 10 HEALTH TECHNOLOGY HAZARDS FOR 2014~2016 (ECRI 2016 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 (3,4,5,7,8,9)，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2項，其中USB埠的誤用，有時會造成機器當機或中斷程式，這是較需要注意的，因為現在很多都是PC Base，USB埠也沒特別封掉，再加上隨身碟及USB裝置又普遍，有時會有人就是好奇，或是想copy資料，就會造成很多意想不到的狀況，這可能是後續要多提醒或製造商要加強硬體資安的管制。
• 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。
• Download our 2016 Top 10 Health Technology Hazards list now to see which 10 safety topics ECRI Institute deems crucial for hospitals to address in the coming year.

	2016	2015	2014
1	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	Alarm hazards   各種不適當警報造成的危害
2	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	Infusion pump medication errors 點滴幫浦的給藥錯誤
3	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	CT radiation exposures in pediatric patients 在兒科患者的CT輻射暴露
4	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	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
5	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	Occupational radiation hazards in hybrid ORs 混合式手術室的職業輻射危害
6	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	Inadequate reprocessing of endoscopic devices and surgical instruments 內視鏡設備和手術器械再處理的不足
7	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	Neglecting change management for networked devices and systems 忽略聯網設備和系統的變更管理
8	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	Risks to pediatric patients from "adult" technologies 使用"成人"技術時導致的兒科患者的風險
9	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	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
10	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	Retained Devices and Un-retrieved Fragments 遺留的物件和無法恢復的碎片