今年的ECRI 醫療科技危害Top10中,IT的議題雖僅1項,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項(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。值得注意的是清潔同時因為操作性的問題,在本年佔了2項,特別是在清潔劑的使用及挑選,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。
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
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2018
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2017
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1
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Hackers Can Exploit Remote Access to
Systems, Disrupting Healthcare Operations
駭客可以利用遠端存取系統方式,干援或破壞醫療系統
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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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2
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“Clean” Mattresses Can Ooze Body Fluids onto Patients
清潔不當可能讓病患身體接觸到到液體的滲出
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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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3
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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
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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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4
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Improperly Set Ventilator Alarms Put
Patients at Risk for Hypoxic Brain Injury or Death
呼吸機警報設置不正確易使患者面臨缺氧性腦損傷或死亡的風險
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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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5
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Mishandling Flexible Endoscopes after
Disinfection Can Lead to Patient Infections
消毒後的內鏡鏡處置不當,可能導致患者感染
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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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6
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Confusing Dose Rate with Flow Rate Can Lead to Infusion
Pump Medication Errors
對劑量率與流速設定若觀念混淆會導致輸液泵藥物誤差
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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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7
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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
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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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8
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Injury Risk from Overhead Patient Lift Systems
病人抬舉設備的傷害風險
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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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9
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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
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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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10
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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
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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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