One Liners Issue 22 - July 2003

SCHWANN SONG
The MHRA has become aware of a case where a gelatine sponge was packed into a spinal surgical site, leading to neurological sequelae when the gel expanded on absorption of body fluids.

• Only pack gelatine sponges loosely in body cavities to prevent expansion damaging surrounding tissues.

WATER SHOCKER!
The MHRA is aware that benchtop ultrasonicators, used as an important first step in the decontamination process, are not always being used appropriately.

• The solution in the water bath should be changed at least when the water is visibly soiled or every four hours. The detergent solution must be compatible with the devices being decontaminated and used at the correct concentration. The unit must be maintained regularly to ensure that the power has not decreased.

HAIR RAISING
We have received a report of burns to a patient following the use of an intense light source for hair removal without appropriate filters.

• Always ensure that a filter has been fitted to the end of the applicator and is replaced as necessary in line with the manufacturer's instruction for use.

EYE SORE?
We are aware of the possibility of corneal burns resulting from inadequate irrigation in small incision phacoemulsification, leading to heat build up.

• Always check your phaco machine is capable of adequate heat distribution before using this new technique.

NEONATAL CARE
A fatality occurred in a maternity unit when an intubated neonate was connected directly to an oxygen flow meter.

• Medical and nursing staff responsible for the resuscitation of mothers and babies must be fully trained and completely familiar with the resuscitation equipment.
  See MDA HN 2002(07).
  In addition, all resuscitation equipment should be easily identifiable for either adult or neonatal/paediatric use and stored separately.

HOT TIP?
The MHRA has received a number of reports of infrared ear thermometers giving low temperature reading in children when incorrectly placed in the ear canal, leading to false reassurance and a delay in medical treatment.

• If advising parents in the use of these thermometers, always ensure the user is familiar with the correct placement of the probe and the need to clean the probe. Advise parents to seek medical advice if there are health concerns, irrespective of the thermometer reading (Medical Device Alert: MDA/2003/010).

Published by the MHRA, an executive agency of the Department of Health. The MHRA was formed from a merger of the Medical Devices Agency (MDA) and the Medicines Control Agency (MCA) on 1 April 2003. If you would like to discuss or report an incident involving a device, contact us on: 020 7972 8123 (medical), 8128 (nursing) or email: devices@mhra.gsi.gov.uk