Medscape gives the following ten examples
1. Surgical Fires: There are an estimated 600 surgical fires per year in US alone leading to devastating consequences, including disfigurement and death. The fire triangle is oxidizers, ignition.
2. Texting While Performing Surgical Procedures:Mobiledevices now make it easier for clinicians to be interrupted for non-work-related reasons. Half of the respondents to a 2010 survey of perfusionists acknowledged texting during heart-lung bypass procedures 2]with 15% further admitting that they accessed the Internet and 3% reporting that they visited social networking sites during procedures. These devices can can divert the caregiver’s attention away from the patient or the task at hand.
3. Dirty Endoscopes and Surgical Instruments: Cross-contamination hazards can occur when flexible endoscopes aren’t properly reprocessed.
4. Using Technology for Adults on Children: Technology designed for adults are used on children as no alternatives exist. They can be risky
5. Air Embolism Hazards: Intravascular air embolism is a potentially lethal complication of certain medical and surgical procedures. The largest percentage of reported events is associated with the use of central venous access devices.
6. Devices and IT Systems That Don’t Interface: Interfaces between medical devices don’t always function as intended and can allow dangerous conditions to exist. For example monitoring system may not communicate audible or visual alarms from an interfaced ventilator to warn caregivers of a critical patient circuit disconnection.
7. Patient Data Errors in EHRs and Health IT: One patient’s data can end up in another patient’s record.
8. Radiation Burns From Diagnostic Radiology Procedures: Inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Image quality typically improves as the dose increases. As a result, there is a tendency to use higher doses that are associated with greater risk to the patient. Acute reactions such as radiation burns and hair loss are relatively rare but still occur too frequently.
9. Medication Administration Errors Using Infusion Pumps: Infusion devices are the subject of more adverse incident reports to the US Food and Drug Administration than any other medical technology, according to the Association for the Advancement of Medical Instrumentation. From 2005 through 2009, more than 700 deaths associated with infusion devices were reported.
10. Alarm Hazards Alarms on infusion pumps, ventilators, and other devices; sheer number of alarms in a hospital can overwhelm staff, leading to complacency and delayed response. Caregivers often turn down the volume of alarms. Too many alarms sounding, can lose its purpose.
No comments:
Post a Comment