Connect with us

Alerts

Cannulas and lines should be removed or flushed post-procedure

Published

on

NHS Improvement has issued a patient safety alert warning that cannulas and lines should either be flushed or removed post-procedure.

A directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure as they can contain residual drugs.

Advertisement

NHS improvement warns that if the IV lines and cannulae are not removed or effectively flushed residual anaesthetic and sedative drugs can later be inadvertently introduced into the patient’s circulation causing muscle paralysis, unconsciousness and respiratory and cardiac arrest.

They go on to say that if the IV lines and cannulae are not removed or effectively flushed residual anaesthetic and sedative drugs can later be inadvertently introduced into the patient’s circulation causing muscle paralysis, unconsciousness and respiratory and cardiac arrest.

You can read the patient safety alert on the NHS Improvement website.

A previous safety alert, ‘Residual anaesthetic drugs in cannulae and intravenous lines’, was issued in April 2014.

Continue Reading
Advertisement
Comments

Alerts

T34 syringe drivers have a risk of unintended pump shutdown

Published

on

The Medicines & Healthcare Products Regulatory Agency have issued the following medical device alert.

All T34 ambulatory syringe pumps are at risk of unintended pump shutdowns and a subsequent delay in providing treatment.

Advertisement

Manufactured by Caesarea Medical Electronics (CME) Ltd – a variation in battery size can cause problems with connections in the battery housing.

The manufacturer has identified that there can be a +/- 2mm overall size difference between battery brands used with CME’s T34 ambulatory syringe pumps. This could result in battery movement within the battery housing leading to a possible loss of connection. This may result in the pump shutting down.

Advise for healthcare staff who use the pump:

  • Identify all affected pumps.
  • Before using the pump, check that the batteries have an adequate connection within the battery housing.
  • You must also check the connections after each battery change.
  • If you find problems with the battery connections, contact your local or hospital servicing department, or CME UK, to arrange for them to adjust the battery housing connection.

If you are a patient using this device the MHRA advice you contact your designated healthcare professional.

You can view the official alert here.

Continue Reading

Alerts

Incorrect use of oxygen cylinders risking patient death

Published

on

NHS Improvement has issued a patient safety alert warning about the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders.

The patient safety alert warns that, following a change to the design of the cylinders, staff may believe oxygen is flowing when it is not, or they are unable to turn the flow on in an emergency.

Advertisement

Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire, valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

You can see an example of how to work an integral valve here, but healthcare staff should seek local advice around which valves are in use.

Between January 2015 and October 2017, over 400 incidents involving the incorrect operation of oxygen cylinder controls were reported to the National Reporting and Learning System (NRLS).

Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious.

The majority of staff reporting incidents believed the oxygen cylinder was either faulty or empty, only later was it discovered that the cylinder controls had not been operated correctly.

You can read the patient safety alert on the NHS Improvement website.

Continue Reading