For most, hospitals are seen as a refuge where the sick may get well. At least, that is the intention of all parties. But there may be more to it, despite the best intentions of everyone to achieve a good end-result. I highlighted earlier in a post on “Highlighting Hospital Hazards for Patients” that complications can occur even in the best medical centres.
While human causes of errors are being actively addressed by management of most hospitals by adopting various quality assurance programs like the ISO standards and ISQUA, the high reliance on machines and technology by themselves create a new set of problems.
The ECRI Institute, the body that researches on patient safety issues and came to the forefront with the Y2K issue at the turn of the century, recently issued the top ten hazards due to technology and devices which occur in hospitals.
New on the list are air embolisms (bubbles of trapped air which travel to the lungs) from the contrast-media injectors used to inject dye into patients for X-ray imaging of blood vessels. Though there are safety features on the injectors to reduce the risk, they aren’t foolproof, and errors can be fatal.
Also new on the list is retained surgical devices — such as a sponge or clamp left in a patient — and “unretrieved fragments,” like a piece of a surgical tool that breaks off and either isn’t noticed by the surgical team or is lodged in a part of the anatomy too risky to attempt retrieval.
Though burns during electrosurgery dropped off the list from 2007, burns from another source made the top 10: the fiber-optic lights used on endoscopes and headlamps to illuminate treatment sites.
Also new on the list: serious problems with anesthesia equipment just before it is to be used on a patient (or after it is too late), including misconnected breathing circuits and ventilator leaks.
Finally, misleading displays on medical devices — such as infusion pumps with confusing displays — can mislead clinicians into making serious errors, like misprogramming medication doses.