One Liners issue 68 - May 2009

ALL medical devices can fail but an increasing number of incidents that result in significant morbidity or mortality arise out of user/device interface problems or because of poor practices. The aim of this news sheet is to detail briefly some of these problems in an attempt to make users more aware of what can go wrong – it is all too easy to take equipment for granted.
Double trouble MHRA have received a report of a patient with an ICD who also had an external pacemaker connected to epicardial pacing leads for temporary pacing support after cardiac surgery. They received an unnecessary shock because of interaction between the two devices. Be aware that interference from other devices can cause an ICD to deliver an inappropriate shock. When planning surgery on a patient with an ICD, you should always seek advice on device management from the ICD follow-up clinic.	Hot patch MHRA have been made aware of the fact that patient who wear nicotine or other drug patches may risk burns during MRI scans. These patches contain tiny amounts of aluminium which can be heated by the device magnet. Such patches should be removed and replaced after scanning if this can be done without affecting patient treatment.
Honey, I flunked the kit!!! Several reports of over-estimation of blood glucose results have been reported when blood glucose meters are used on samples of systemic treatments that contain, or are metabolised to, maltose, xylose or galactose. The problem does not apply to treatments taken orally. Be aware of solutions that contain these products such as peritoneal dialysis fluid and some immunoglobulin treatments. If you are unsure, consult the medicines information department of your local hospital pharmacy.	Cable scar MHRA have become aware of small holes and splits being found in power cables. Investigation found that this was due to the cables being trapped in the holding baskets during re-processing. Ensure that staff are aware that care should be taken when packing devices with cables for storage or re-processing to prevent such problems occurring.
Arc angel? MHRA is aware of an incident involving the application for monopolar diathermy on vessels on which a tantalum containing liquid embolic glue had been used. This resulted in an electrical arcing and smouldering in the vessels. Avoid using monopolar electrocautery devices in such cases and only use bipolar devices with caution.	Succour! MHRA has received several reports of staff reducing the length of an endotracheal tube with scissors and inadvertently cutting through closed endotracheal suction devices left inside the endotracheal tube, the distal portion passing down into the trachea requiring interventional removal. Ensure that all manipulation of endotracheal tubes is done according to their instructions for use and after appropriate training.
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.