One Liners issue 57 - April 2008

gluClose Call
Measuring blood glucose levels on pre-term neonates? Using a blood glucose meter on the ward? STOP!

• Only use meters that have been validated for use in pre-term neonates. If the meter is not specifically validated for such use, then a laboratory method should be used. If in doubt, check with the laboratory.

Honey I Shrank The………...
Measuring blood glucose on the neonatal ward? Ensure your blood glucose meter is validated for use in neonates.

• Always check the instructions for use. Some blood glucose meters are not accurate at low concentrations and use methodology which can be affected by high haematocrit and low plasma volumes found in neonates. If in doubt, check with your laboratory.

Crush Call?
MHRA has received reports where mechanical chest compression devices have trapped the fingers of device operators and those undertaking manual chest compression during positioning of the device. These devices exert considerable force when compressing the chest for cardiac massage.

• Ensure that the compression device is fitted according to the manufacturer’s instructions. Do not commence chest compression until it has been established that all personnel are clear of the device.

Filter!!!!
MHRA has received a report of an electrostatic breathing system filter becoming blocked by excessive sputum. Blockage by secretions is a well recognised problem despite claims that electro-static filters may be less susceptible.

• This feature should not be relied upon as all filters may become blocked by excessive secretions.

Talking Up A Recession?
MHRA is aware of reports of the top/ septum of needlefree intravascular connectors remaining in a recessed position following use.

• If top/septum remains recessed, replace the connector as there is a risk of infection. (see MDA/2008/016)

Stress Incompetence?
MHRA has received reports of Stem Cell Cryocyte freezer bags leaking at the insertion of the donor tubing. Stress placed on the donor tubing when tearing off after sealing may have contributed to this leakage.

• Follow the instructions for use including specific instructions relating to the detachment of the donor tube (ie if the instructions state that donor tube should be cut after sealing).

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.