One Liners issue 73 - December 2009

PosTOOLATE?
MHRA is aware of a number of instances where a poorly adjusted posture belt in seating for a disabled child has allowed them to slip down and fall or suffer positional asphyxiation.

• Ensure that posture belts are fully functional and properly adjusted before and during use. See MDA 2008/037

Schoolboy error?
Mobility and other devices used by children which are not checked before use or are not regularly maintained have failed in use leading to injuries and fatality.

• All devices should be checked before use and regularly maintained in accordance with the manufacturer's instructions. See MDA 2005/02

THE-MOM et EAR
Infrared ear thermometers may give low temperature readings when not correctly placed in the ear canal.

• The ear canal may have a temperature of 2°C lower than the tympanic membrane. Ensure that ear thermometer probes are positioned to detect heat radiated from the tympanic membrane to avoid falsely low readings.

Listen up!
Children with cochlear implants are at an increased risk of contracting pneumococcal meningitis.

• Ensure that children receiving cochlear implants have been immunised in line with the Department of Health recommendations (Immunisations against Infectious Disease. The Green Book, Chapter 25 (external link)).

Unschooled dinnerrs
Some syringe drivers with software for recognising IV syringes may incorrectly recognise oral/enteral feeding syringes. There is a risk of inaccurate delivery of enteral feed which could be significant in paediatrics particularly pre-term neonates.

• 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.

Sugarbabes?
Not all blood glucose monitors are suitable for use in neonates. Some devices are suitable for blood glucose monitoring but not diagnosis of hypoglycaemia.

• Always ensure that you choose an appropriate method for monitoring blood glucose and diagnosing hypoglycaemia in neonates in your care. If in any doubt use a laboratory method.

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.