One Liners issue 58 - May 2008

Bone of Contention?
MHRA has received reports of failed attempts to gain intraosseus access during resuscitation.

• Users should be aware that the recommended access sites vary for different intraosseous devices. Always follow the manufacturer’s instructions for use.

Cock-A-Leekie
MHRA has received reports of intrathecal drug pumps leaking at their connector site, resulting in localised tissue reaction and a reduction in treatment efficacy. This may be due to the use of combinations of different manufacturer’s devices.

• Connecting pumps and tubings using a connector from a different manufacturer may increase the risk to the patient and potentially open hospitals to medicolegal claims.

A Spine Mess
MHRA has received reports of a higher incidence of intrathecal morphine sulphate pump catheter tip granulomas, than is currently recognised. This may be as high as 3%.

• Clinicians should ensure that the presence of tip granulomas are considered if the efficacy of the morphine is apparently reducing.

Off Yer Trolley
MHRA continues to receive reports of complete or partial collapse of ambulance stretcher trolleys where no specific fault is found.

• Ensure that retaining clips and latches for stretcher trolley legs, back rests and other parts are correctly locked in place and that routine maintenance is carried out in accordance with manufacturer’s instructions.

Wires Crossed?
MHRA have received reports of individual non-labelled lead wires of 12 lead ECG recorders being accidentally pulled out from the ECG cable block and being plugged back into the incorrect port, resulting in inaccurate ECG readings.

• It is recommended that IEC colourcoded lead wires are purchased where possible and that daily checks are carried out to trace each individual lead wire from the patient back to the appropriate ECG cable block connector to ensure the correct location.

Cracking Up!!
Using cracked plastic mounting brackets on ‘trombone’ type bed rails has led to failure of the bracket, with the occupant falling out of bed and sustaining serious injury.

• Ensure bed rails and their mountings are regularly checked and replace any which have cracks or other signs of damage.

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.