One Liners issue 46 - January 2007

Drop Zone?
We continue to receive reports where ceiling mounted ancillary equipment, e.g. operating lights/injector pumps becoming loose, and in some cases fall down, with the potential for serious staff/patient injury.

• Please remember to include all such equipment on regular maintenance schedules.

Bottoms Up!
Many cushions in wheelchairs have a top surface filling which is contoured to help reduce the risk of pressure ulcers for the occupant. Cushions, however, are frequently seen upside down or rotated through 90º or 180º, which can put the user at increased risk from pressure ulcers.

• Always check that wheelchair cushions are orientated correctly.

Tip Off!
MHRA has received a number of reports of catheter tips breaking on removal, often requiring interventional surgery for retrieval. Always (visually) check tips of intra-vascular devices, including catheters, guide wires, introducers, etc, after removal, to ensure the tip is intact.

• Always use according to the instructions for use.

A Squirt in Time
MHRA has become aware of incidents concerning poor connection of luer lock syringes/cannulae in cataract surgery causing such cannulae to detach with force into the eye when the syringe is depressed. This has lead to serious eye injury such as retinal detachment and choroidal haemorrhage.

• Ophthalmic staff should always check that luer lock devices are connected correctly and working safely prior to intra-ocular use.

Hyper-pyrexial?
MHRA has received a report of a power supply to a monitor screen being covered by books at the rear of the screen. Because it was unable to dissipate heat, the plastic case became so brittle, it collapsed when picked up by the user.

• Small mains connected power supplies similar to those used to power laptop computers or monitor screens, should have sufficient space to dissipate their heat.

Killer pascals!
MHRA has received reports of serious injuries to patients’ arms due to automatic NIBP monitor cuffs failing to release their pressure through kinking or trapping of the rubber hose used to couple the monitor to the cuff. Even if the monitor is switched off, the pressure will remain and the user’s attention cannot be drawn to the “deflate failed, remove cuff” message that would have been available on the screen.

• Users should always remove cuffs when the monitor is not being used.

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.