One Liners issue 71 - September 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.
Lightening the load The MHRA is aware of reports of anaesthetic machines becoming unstable when moved due to overloading with additional equipment, such as monitors, which have not been approved by the machine manufacturer. This can cause the anaesthetic machine to become unstable and tip over, with the potential for causing serious injury to the patient or hospital personnel. Never overload any machinery. Always check manufacturer’s instructions for use for details of approved accessories.	Live wire The MHRA is aware of a user receiving an electric shock from a cracked mains power on/off switch. The device was over five years old and had no maintenance history. Please ensure that switches are checked regularly and included in preventative maintenance and pre-use checks. Always ensure that regular maintenance of devices is carried out in line with manufacturer’s instructions.
A shocking reminder... ...that wet hands and electricity do not mix! MHRA are aware of an incident where a user received an electric shock when a defective switch was operated with wet hands. Users are reminded to avoid touching any power sockets and switches with wet hands in order to ensure personal safety in such circumstances.	Food for thought Some syringe drivers with software for recognising IV syringes, may incorrectly recognise oral/enteral feeding syringes. In these circumstances, there is a risk of inaccurate delivery which may be  significant particularly in paediatrics. If you must use oral/enteral syringes in IV syringe drivers, regularly check the volume of feed delivered to ensure that the delivery rate is appropriate. Consider alternative delivery methods.
Press sure The MHRA has received reports of pressuretransducers within haemodialysis/haemofiltration machines being contaminated with blood. This occurs after machines have had bloodline components inserted incorrectly, resulting in pressure build-up within the machines forcing blood into the machine via the pressure transducer. These faults are not always detected during priming. When inserting bloodlines into dialysis machines, ensure that all necessary components are seated in the appropriate fittings correctly.	Nebu-loss? The MHRA has become aware of blockages of breathing system filters and damage to flow measuring probes caused by the nebulisation of drugs through the breathing system. Always closely monitor airway pressures during and after nebulisation ensuring that any flow measuring probes are suitable for such conditions. Special care should be taken if the medicine being used is not specifically intended for nebulisation.
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. You may also use this online system to send an email 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.