One Liners issue 56 - March 2008

Loosing the thread?
We have received some reports of the X-Ray detectable filaments in X-Ray surgical swabs being incomplete, or broken or in some cases missing.

• Ensure the X-Ray detectable filament is present and intact in each swab before use.

“I counted them all in ….”
We continue to receive some reports of packs of tied-5s swabs containing the wrong number of swabs which can cause unnecessary delays in operations.

• Check that packs of tied-5s swabs do contain 5 swabs, no more, and no less.

Cut loose!!!
We have had occasional reports of loose fibres apparently shedding from surgical swabs used during open surgery potentially contaminating the surgical site.

• Keep swabs intact and do not cut them or open them out exposing raw edges.

Losing your Tag?
Some swabs available with sewn in tags or tapes for easy retrieval from the surgical site have been reported to be insecure or c o m p l e t e l y detached.

• Ensure that any tags or tapes sewn onto swabs for easy retrieval are fully secure.

Invisibly Intense
Radiopaque swabs left in the body following an operation can be difficult to find using an image intensifier in theatre.

• Under these circumstances a plain X-Ray may be helpful.

The Human Torch…
A recent report has highlighted a fatal incident in which a paraffinbased skin product in contact with a patient’s dressings and clothing was ignited by a naked flame (www.npsa.nhs.uk/health/alerts).

• It should be noted that the same basic precautions will also apply for gauze dressings already impregnated with paraffin, known as “tulle gras”.

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.