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One Liners issue 51 - September 2007

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Document details:

Type: Publication
Series No: Issue 51
Audience: Healthcare professionals
Published: September 2007
Format: Electronic and paper
Size: A4
Pages: 1
Price: free
ISBN/ISSN:
Author: MHRA
Copyright: Crown
   

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. A significant number of issues reported to us relate to anaesthetic and ventilation devices. We have dedicated this issue to highlighting a number of recent problems in this area.

ET Gone Home
MHRA is aware of a number of luer nozzles from syringes breaking off into the air insertion port during the inflation of an ET tube, rendering them unusable.  It is understood that syringes are, on occasions, repeatedly used for this purpose.

  • Repeated use of a single use device can result in breakage and failure.  Single use devices should be used once and then discarded, irrespective of the purpose for which they are used.

Not Needled!
MHRA is aware that the instructions for use for several brands of needle free intravascular connectors have recently changed significantly.

  • Staff using these devices should check that up to date instructions are available and pay particular attention to the following where appropriate:  maximum period of use or maximum number of activations; suitable or unsuitable disinfectants to swab connectors; and a statement relating to the contact and drying time of the recommended disinfectant(s).

Un ray liable
Users should be aware that stray radiation from linear accelerators may corrupt the memory chips in medical devices used in their vicinity.  It is difficult to identify which devices could be affected, as not all device manufacturers’ instructions advise users of this problem.

  • MHRA advises that, unless the manufacturer states otherwise, if a device (eg an infusion pump) cannot be removed from the patient during therapeutic radiation sessions, it should be adequately shielded and its ability to function correctly tested following the treatment.

One Liner Questionnaire
The results of a recent questionnaire carried out to assess aspects of One Liners demonstrated:

  • 94% like the style/layout/presentation
  • 88% found the information helpful
  • 87% found the information contained was about right
  • 90% found the frequency of publication appropriate 

A big thank you to all those who contributed.

Don’t s’COUGH
MHRA receives significant number of reports where pieces of stylets have been shaved off on removal from the endotracheal tube and migrated into patients’ lungs.

  • Ensure that manufacturers instructions for use are always followed, as they may provide guidance on lubrication and compatibility with other devices.  If difficulties are encountered removing the stylet from the endotracheal tube, then the tube must be removed and a new stylet 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.


Page last modified: 01 October 2007