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Showing results for tags 'Medical device / equipment'.
Found 218 results
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
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News Article
Australian women win landmark vaginal mesh class action against Johnson & Johnson
Patient Safety Learning posted a news article in News
Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson. The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth. The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard. The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved. Read full story Source: The Guardian, 21 November 2019 -
Content ArticleFor over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also watch the short video kindly made for me by Knowlex UK.
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Content ArticleA National Patient Safety Alert has been issued around the risk of depleted batteries in intraosseous injectors. The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible to administer medicines or fluids, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector. As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work. The alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to regularly check these devices to ensure sufficient battery power remains so the devices are always ready and available.
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Content Article
Electrosurgery. Managing the risk (September 2004)
Patient Safety Learning posted an article in Surgery
This poster from the National Association of Theatre Nurses (ATN) aims to give an overview of electrosurgery in the perioperative setting. It identifies and defines some of the common forms of electrosurgery used in perioperative practice and identifies some of the hazards that can be associated with these products. -
Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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Content ArticleThis report from Saaiq and colleagues, published in the Annals of Burns and Fire Disasters, highlights three cases of iatrogenic electrocautery burns with review of the relevant published literature. The aim is to prompt awareness among surgeons and theatre staff regarding this avoidable hazard associated with the equipment frequently used for the purpose of electrocautery. This may serve as a reminder to professionals to be cautious about the pitfalls that lead to such preventable injuries.
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Content Article
MHRA: The Yellow Card Scheme
Claire Cox posted an article in Adverse interactions
The Yellow Card Scheme helps the Medicines and Healthcare products Regulatory Agency (MHRA) monitor the safety of all healthcare products in the UK to ensure they are acceptably safe for patients and those who use them. On the Yellow Card Scheme website you can report a suspected incident or problem. -
Content ArticleThis case story highlights the missed opportunities that could have prevented a cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. MHRA is an executive agency, sponsored by the Department of Health and Social Care. Recognised globally as an authority in its field, the agency plays a leading role in protecting and improving public health and supports innovation through scientific research and development. The agency has 3 centres: Clinical Practice Research Datalink (CPRD), a data research service that aims to improve public health by using anonymised NHS clinical data the National Institute for Biological Standards and Control (NIBSC), a global leader in the standardisation and control of biological medicines the Medicines and Healthcare products Regulatory Agency (MHRA), the UK’s regulator of medicines, medical devices and blood components for transfusion, responsible for ensuring their safety, quality and effectiveness.
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Content ArticleSalford Care Organisation uses this great infographic on their wall to show patients and relatives what they may experience when on the intensive care unit.
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Content ArticleCataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable. Read the Healthcare Safety Investigation Branch's report on the insertion of an incorrect intraocular lens.
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Content ArticleVideo recording technologies offer a powerful way to document what happens in clinical areas. Cameras, and to a lesser extent, microphones, can be found in a growing number of modern operating rooms in the USA, UK and other parts of the world. While they could be used to create a detailed record of what happens in and around the operating table, this is still rarely being done; the vast majority of operations are still only documented in written operation notes. In this paper, Bezemer et al. discuss using microanalysis of videos from the operating room.
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Content ArticleThe Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilisation of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This is an American guidance from the Centers for Disease Control and Prevention.
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Content ArticleThe American based ECRI Institute Patient Safety Organization (PSO), identified 234 events in its database pertaining to dirty surgical instruments. This report contains several recommendations based on the findings.
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Content ArticleThis American report describes events involving dirty instruments submitted to ECRI Institute Patient Safety Organization and other reporting agencies. It provides recommendations to improve reprocessing practices, with a focus on instrument decontamination and the cleaning that occurs before disinfection or sterilisation.
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Content ArticleThis is a Health Technical Memorandum (HTM) published by the Department of Health and Social Care (DHSC) called Management and decontamination of surgical instruments (medical devices) used in acute care. Part A: Management and provision. The purpose of this HTM is to help health organisations to develop policies regarding the management, use and decontamination of reusable medical devices at controlled costs using risk control, which will enable them to comply with Regulations 12(2)(h) and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . It is designed to reflect the need to continuously improve outcomes in terms of: patient safety clinical effectiveness patient experience.
