One Liners

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.

Some editions focus on a specific device or theme or are of interest to primary care trusts.

Latest One Liners

• 30 Jan 2012 | One Liners issue 91 - January 2012
  

  The aim of this edition is to highlight common issues that have been encountered and provides guidance on preventing problems in the future.

• 22 Nov 2011 | One Liners issue 90 - November 2011: Assistive Technologies Special Issue
  

  This news sheet is aimed at healthcare professionals and highlights incidents involving slings and hoists which have resulted in serious injury or even death.

• 26 Oct 2011 | One Liners issue 89 - October 2011: Wheelchair use
  

  This edition highlights common issues that have been encountered with wheelchair use and provides guidance on preventing problems in the future.

• 10 Oct 2011 | One Liners issue 88 - October 2011
  

  This news sheet is aimed at healthcare professionals and highlights concerns relating to the use of medical devices. This issue covers topics including interference in ECG monitors and metric/imperial equivalents for vascular devices.

• 09 Sep 2011 | One Liners issue 87 - September 2011: Dialysis special editon
  

  This news sheet is aimed at healthcare professionals and highlights concerns relating to the use of medical devices. This issue covers topics including haemodialysis and haemofiltration machines alarms being overridden and dialysis bloodlines which have 'kinks' present during treatment.

• 02 Aug 2011 | One Liners issue 86 - July 2011
  

  This news sheet is aimed at healthcare professionals and highlights concerns relating to the use of medical devices. This issue covers topics including nebulisers being inappropriately inserted into the breathing systems of patients with endotracheal and tracheostomy tubes and delays in administrating emergency drugs because of incompatibility between prefilled syringes and needlefree connectors.

• 13 Apr 2011 | One Liners issue 85 – April 2011
  

  This news sheet is aimed at healthcare professionals and highlights concerns relating to the use of medical devices. This issue covers topics including siphoning during the use of syringe pumps, and procedures for using contrast media injectors.

• 16 Mar 2011 | One Liners issue 84 - March 2011: Maintenance special
  

  An increasing number of incidents that result in significant morbidity or mortality arise because of lack of maintenance. This edition of One Liners to aims to detail some of the problems that have been reported as a result of maintenance failure and to highlight the importance of this aspect of medical devices.

• 08 Feb 2011 | One Liners issue 83 - February 2011: Blood glucose monitoring equipment in paediatrics
  

  The MHRA receives reports of harm or near misses associated with blood glucose monitoring equipment in paediatrics. This edition of One Liners describes some of these problems with advice on preventing further incidents in the future.

• 24 Jan 2011 | One Liners issue 82 - January 2011
  

  This news sheet is aimed at healthcare professionals and highlights concerns relating to the use of medical devices. This issue covers topics including reports of patients becoming hypotensive whilst receiving cell salvaged autologous blood, problems with pulse oximetry probe cables, leg ulceration from anti-embolism stockings and unintended delivery of nitrous oxide mixture rather than pure oxygen during patient pre-oxygenation before surgery.