One Liners issue 69 - June 2009

MHRA receives relatively few reports from the front line responders of the ambulance services. However, the situations encountered are stressful for both the equipment and staff resulting in serious issues with medical devices and drug delivery systems.

Due to the urgent nature of emergency care, the reporting of incidents can be difficult; therefore the aim of this dedicated issue is to detail briefly some of the problems encountered by ambulance staff in an attempt to make them more aware of what can go wrong and to encourage incident reporting.

Don't go spare!
MHRA has received reports of damage to single use laryngeal airway devices which occurred during manufacture. This failure was found during the recommended pre-use checks. However there were no spare tubes available.

• Always ensure that spare laryngeal airway devices and endotracheal tubes are carried. Where space is an urgent issue, ensure that at least there are spare devices of the most commonly used sizes.

Running on empty
MHRA Defective Medicines Reporting Centre continues to receive reports from the Ambulance Service where supposedly “new” boxes of pre-filled syringes are found to contain empty syringes.

• Ensure that all used pre-filled syringes are accounted for after patient use and replaced appropriately. At the start of each new shift ensure you check that all drugs including pre-filled syringe packs are intact and ready for use.

Ignition… lift off!
MHRA has received reports of oxygen cylinder fires whilst in use by the ambulance service. Whilst it is difficult to establish the exact cause of the ignition, it is known that the cylinders were stored near alcohol hand wash and oils/lubricants.

• Always store cylinders safely. Whilst cylinders are in use, or stored in the ambulance, be aware of possible sources of contamination especially alcohol based hand washes. The MHRA has published a Top Tips for the care and handling of oxygen cylinders and their regulators, which is available to download from the website.

Shock-err!
A number of incidents have been reported where defibrillators have failed to detect that the electrodes were attached to the patient but on investigation no faults were found. One possible cause of this problem is ‘slapping’ the electrodes onto the patient. This can trap air under the electrodes resulting in poor connection.

• Defibrillator electrodes should be smoothed or rolled onto the patient’s chest to ensure good adhesion and electrical contact, according to the manufacturer’s instructions.

Off yer trolley?
MHRA continues to receive reports of complete or partial collapse of ambulance stretcher trolleys, where no specific fault could be established.

• 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.

Lost in transmission
ECG traces are often filtered to reduce artefact and baseline wander. Filtering can affect the subtle changes indicative of myocardial ischaemia. This can have a greater effect when using telemetry systems so that the ECG transmitted to the receiving centre may not look the same as that displayed in the ambulance.

• Filtered ECGs are useful for general arrhythmia monitoring but not for diagnosis of ischaemic changes (ST segment elevation). Filters should be switched off when performing diagnostic 12 lead ECGs.

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.