今年的ECRI 醫療科技危害Top10中，光IT的議題就有4項，但是關係到IT技術如勒索病毒、網路安全的議題有二項,另二項是關係到使用者操作的問題。由此可以看到IT工具普及後，若使用者在使用習慣跟資安的認知不足的情形下，IT所導致的醫療風險會越來越多,這是我們醫工要改變傳統的醫儀維修思考及操作模式,同時資管軟、硬體人員,也需要體會到,在病人安全及醫療品質的大前提下,臨床使用教育訓練的責任正在提高中。
https://www.ecri.org/Resources/Whitepapers_and_reports/Haz_18.pdf
https://www.ecri.org/Resources/Whitepapers_and_reports/Haz_18.pdf
2018
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2017
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2016
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1
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Ransomware
and Other Cybersecurity Threats to Healthcare Delivery Can Endanger Patients
(IT)
勒索軟體和其他威脅醫療保健服務網絡安全的軟體，可能會危及患者安全
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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
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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
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2
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Endoscope
Reprocessing Failures Continue to Expose Patients to Infection Risk
內視鏡再處理失敗會持續使患者曝露於感染風險中
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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
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Missed
Alarms Can Have Fatal Consequences
未處理的警報會有致命的後果
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3
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Mattresses
and Covers May Be Infected by Body Fluids and Microbiological Contaminants(感控問題)
床墊和床罩可能會遭病人體液和微生物污染所引發的感染問題
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Missed Ventilator Alarms Can Lead to Patient Harm
呼吸器警報疏忽會導致病人傷害
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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
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4
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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)
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Undetected Opioid-Induced Respiratory Depression
未察覺鎮痛藥物所引發的呼吸抑制
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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
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5
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Improper
Cleaning May Cause Device Malfunctions, Equipment Failures, and Potential for
Patient Injury
不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)
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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
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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
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6
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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，可能會因誤觸開關，導致患者灼傷
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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
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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。
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7
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Inadequate Use of Digital Imaging Tools May Lead to
Unnecessary Radiation Exposure
數位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)
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Occupational Radiation Hazards in Hybrid Ors
複合式手術室的職業輻射危害
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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
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8
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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。
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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
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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
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9
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Flaws
in Medical Device Networking Can Lead to Delayed or Inappropriate Care
醫療設備網路的缺陷可能會導致延遲或不當護理 (IT)
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Surgical Stapler Misuse and Malfunctions
手術釘合器誤用及故障
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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
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10
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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會使患者面臨誤接輸液的風險
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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
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Misuse
of USB Ports Can Cause Medical Devices to Malfunction
誤用USB埠會造成醫療設備故障
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