One Liners Issue 13 - February 2001

Steamed up!
MDA has received a number of reports of patients who have had to be recalled for vaginal examination because vaginal speculae had not been adequately sterilised following cleaning.

• MDA recommends the use of steam sterilisation at 134°-137°C for 3 minutes rather than dry heat sterilisation (hot air ovens) because it is quicker, more effective and more controllable. See SAB(94)23: Dry heat sterilisers: Purchase, Maintenance and Use; DB 9605: The Purchase, Operation and Maintenance of Bench-top Sterilisers.

Stripped To The Bone
MDA has received an unusual report of an incident where the patella button component of a total knee replacement was inadvertently dislodged by a vein stripper.

• All surgeons involved in vascular work should take care when stripping veins in the presence of a total knee replacement implant.

Under Pressure!
MDA has received a number of reports of pressure or necrosis or blistering resulting from the use of tape to hold the pulse oximeter probes in place for prolonged application.

• Do not use tape to hold the probe in place unless specified by the manufacturer. Check and resite the probe in accordance with the manufactures' instructions or more often if indicated by circulatory status and/or skin integrity.

Silent Witness
MDA has learnt of a hospital where it was routine to place adhesive tape over the loudspeaker of an alarm on a critical care monitor. The hospital has now taken steps to ensure that staff discontinue this practice.

• Alarms are there to alert clinical staff of a change in the patient's condition and must never be muted in this way.

Food for Thought
There is a risk of microbial contamination of enteral feeding sets. For vulnerable patients (e.g. immuno-suppressed and cancer patients) the risk is minimised by the use of sterile feed and single-use components. In other circumstances, where reusable products are used, particular care is necessary in following the cleaning, decontamination and change intervals recommended by the manufacturer.

• Please let us know if you have experienced any problems or confusion over the choice or use of enteral feeding sets.

Invisible Ink
CTG and ECG charts printed on thermal paper only remain legible for five years.

• For longer storage (which is required by HSC 1999/053), alternative means of storage should be considered, e.g. photocopy, microfilming, electronic or optical storage.

Published by the Medical Devices Agency - an executive agency of the Department of Health. We investigate problems arising from the use or misuse of medical devices when health or safety have been put at risk. If you would like to discuss or report an incident or request any of the publications referred to above, contact us on 020 7972 8123 (medical), 8128 (nursing) or e-mail : clin@medical-devices.gov.uk