2020

2019

2018

1

Misuse of surgical staplers.

外科縫合器的誤用。

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

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

2

Adoption of point-of-care ultrasound (POCUS) Is outpacing safeguards.

即時護理超音波的普及使用超越了保障措施

“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

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

3

Infection risks from sterile processing errors in medical and dental offices

醫療和牙科診所的無菌處理錯誤會導致感染風險。

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

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

4

Hemodialysis risks with central venous catheters, and how the push toward home dialysis may Increase the risks.

置放中央靜脈導管後在居家透析時所造成的血液透析風險。

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

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)

5

Unproven surgical robotic procedures may put patients at risk.

未經實證的手術機器人用程序可能會使患者處於危險之中。

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

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)

6

Alarm, alert and notification overload.

警報，警示和通知造成人員感知過載。

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

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

7

Cybersecurity risks in the connected home healthcare environment.

居家照護醫療環境中的連網安全。

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

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)

8

Missing implant data can delay or add danger to MRI scans.

體內植入物缺少相容資訊時會增加MRI掃描時的風險。

Injury Risk from Overhead Patient Lift Systems

病人抬舉設備的傷害風險

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。

9

Medication errors from dose timing discrepancies in EHRs.

藥品開立時間與EHR時間的差異所引起的用藥錯誤。

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

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)

10

Loose nuts and bolts can lead to catastrophic device failures and severe injury.

鬆動的螺母和螺栓可能導致設備故障和嚴重傷害的災難。

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

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