One Liners issue 55 - January 2008

Pulp Fiction Some general waste containers made of pulp material may leach substances such as nitrites into the collected urine specimen. These substances could interfere with urine dipsticks and lead to false results.

• Choose a specimen collection device suitable for use with urine dipsticks.

Explosive Recipe MHRA has received a report of the rupture of a medical air hose connected on an intensive care ventilator. It was found that the hose had been melted by the heat of a reading lamp placed next to the ventilator.

• Medical gas hoses must be kept away from any source of heat, such as reading lights, to prevent the risk of fire or explosion.

Never Again! A single use neonatal endotracheal tube introducer broke off and remained in the endotracheal tube resulting in a neonate becoming hypoxic and bradycardic. The intubation stylet was discovered to be highly deformed indicating that it had been used on more than one occasion.

• Only use a single use device for one procedure. Always follow the manufacturer’s instructions for use and do not excessively bend intubation stylets. If difficulties are encountered removing the stylet from the endotracheal tube, then the tube must be removed and a new stylet used.

c’OUCH! A portable examination couch collapsed and folded up during treatment, injuring the patient and the physiotherapist. The couch had been overloaded and had not been regularly maintained.

• Always ensure portable examination couches are maintained in accordance with the manufacturer’s instructions and are not loaded beyond their safe working load.

Not eye deal! MHRA has received a report of povidone iodine staining intra ocular lens material causing it to become opaque.

• This solution should not be used on the open wound following intra ocular lens implantation.

Just a Trim, Sir? MHRA have received reports where tracheostomy tubes have fallen out due to failure of the securing tabs on the tracheostomy tube holder. The securing tabs had been excessively trimmed by the user, resulting in the stitching falling apart.

• Always ensure that tracheostomy tube holders are fitted according to the manufacturers instructions. Care must be taken when trimming any excess material from the securing tabs of the tube holder.

The One Liners Editions are published by the MHRA, an executive agency of the Department of Health. Adverse incidents should be reported at the earliest opportunity. We prefer to receive reports via the online reporting system on our website www.mhra.gov.uk

You may also use this online system to send an e-mail copy of your report to your medical device liaison officer. We also have an adverse incident hotline: 020 7084 3080. You can find detailed reporting guidance on our website.