One Liners issue 53 - November 2007

Bloodsucker? MHRA has received reports of adverse incidents occurring during blood collection, including needles disconnecting from their holders and sample tubes becoming stuck within the needle holder. These have occurred when using an incompatible combination of devices from different manufacturers.

• Users should check manufacturers’ instructions for use, then ensure that needles, needle holders and sample tubes are compatible.

Lighten the Load. MHRA is aware of a report of an incident where a castor on an anaesthetic machine broke when the machine was being moved. The machine tipped over with the potential for causing serious injury to the patient or hospital personnel.

• Investigation revealed that the machine had been overloaded with
  an additional patient monitoring system not tested for stability or
  approved by the manufacturer.

i-LUMEN-ating. When more than one lumen of a multi-lumen extension set is in use, backtracking of IV fluids may occur. This results from IV fluids being run through one of the lumens, whilst the second lumen has no fluid or a slower running fluid infusing through it. This can also occur if an occlusion is present in the IV catheter.

• Be aware that bolus delivery will occur when occlusion is released, the lumen is flushed or flow is increased in that lumen.

No Going Back!! MHRA has received a report of backtracking of IV fluids via needle free connectors attached to IV lines. These connectors allow fluids to be infused and withdrawn and, therefore, will not prevent backtracking.

• Where appropriate, consider using IV lines with one-way valves to prevent backtracking. Apply clamps (where available) to lumens/lines not in use.

Missing the Point? MHRA is aware of a number of instances where there have been reports of failure to produce an effective spinal block when needles with side holes are used. This many be due to loss of the drug into the extradural space.

• Always ensure that, when using such needles, the openings are fully in the CSF so that the correct dose of local anaesthetic is administered.

Filter Tip. MHRA is aware of an incident of a patient presenting with a peri-anal abscess with initial failure in attempts to aspirate. On changing the needle to a non-filter variety, drainage was immediately achieved.

• Always ensure that the correct needle is used for the correct procedure, checking the manufacturer’s instructions for use. (With thanks to CORESS - Confidential Reporting System in Surgery )

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.