Search the hub
Showing results for tags 'Medical device / equipment'.
Found 56 results
-
News ArticleMore than 200 people who went through hotel quarantine in Victoria, Australia, must be screened for HIV amid fears of cross-contamination from incorrect usage of blood glucose test devices. Several such devices were used on multiple people in quarantine between 29 March and 20 August, necessitating screenings for blood-borne diseases such as hepatitis B and C and HIV. These monitors, which take a small sample of blood from a fingertip, are intended for repeated use by only one person. While the needle is changed between usages, microscopic traces of blood can remain within the body of the machine, creating a low clinical risk of cross-contamination and infection. Safer Care Victoria, the state’s healthcare quality and safety agency, has assured the public there is no risk of COVID-19 spread as the disease is not transmitted by blood. These devices have since been taken out of circulation. In a statement, a spokesman for the agency said they have identified 243 people who had been tested by one of the shared machines during the timeframe in question, and will be contacted for screening. Everyone “who had conditions or episodes that may have required the test will also be contacted as a precaution”. The Victorian premier, Daniel Andrews, labelled the incident a “clinical error that was made some time ago”. “Safer Care Victoria have made some announcements in relation to a clinical error that was made some time ago, very low risk, but you can’t take any risks with these things. You have to follow them up properly and that’s exactly what has happened,” he said at a press conference on Tuesday. Read full story Source: The Guardian, 20 October 2020
-
News Article
Ontario woman finds needle in her spine 16 years after giving birth
Patient Safety Learning posted a news article in News
When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine. It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births. She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility. More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems. Read full story Source: CBC, 5 October 2020 -
News ArticleHospitals have been warned hundreds of ventilators used to keep sedated patients alive are at risk of suddenly shutting down because of a fault, in some cases without warning. The Medicines and Healthcare products Regulatory Agency, which said there were approximately 303 Philips Respironics V60 ventilators used in the UK, has warned hospitals over a delay in replacement parts arriving in the UK to fix the problem. It has issued a safety alert to hospitals to make them aware of the increased risk. The regulator said it had received one report of a ventilator suddenly shutting down but said there was no report of any injury to patients. Read full story Source: The Independent, 23 September 2020
-
Content ArticleActions required Primary actions to be completed by 7 October 2020: Identify and locate affected devices in your organisation. Identify alternative ventilators available on site. If no suitable alternative available, and capacity is an issue currently or expected imminently, follow protocol for resource shortage escalation set out by your local governance. Train all relevant staff on alternative ventilators and ensure training records are up to date. When actions 1–4 are complete, remove affected V60s from use and quarantine until repaired by the manufacturer. Place the alternative devices into service in place of the affected V60s. You may continue to use affected V60s if there is a risk of severe patient harm due to lack of ventilator availability. A thorough risk assessment must be completed, and additional monitoring must be used. A backup form of ventilation must be available at all times. Secondary action to be completed by 23 December 2020: 8. Review procurement and stock policies to ensure you are not reliant on one manufacturer or model of ventilator.
-
Content Article
-
Content ArticleDuring the debate on the second reading of the Bill there were contributions from a range of parliamentarians, reflecting on how it related to the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). Some points of interest from the debate included: Baroness Cumberlege noting concerns that "rumours are absolutely rife of a ritual burial" of the First Do No Harm report. She noted plans to create a parliamentary group called First Do No Harm to ensure the recommendations of the report were implemented. She stated her intention to put down an amendment to the Bill to include a proposal to appoint a patient safety commissioner, one of the key recommendations of the report. In his closing comments Lord Bethell, Parliamentary Under-Secretary of State (Department of Health and Social Care), noted that this amendment had support from a number of members of the House of Lords and that they had sent "a clear message to the Government and the public that patient safety must be paramount in how we regulate medicines and medical devices". Follow the link below for the full transcript.
-
Content Article
-
News Article
Patient bleeds to death in hospital run by scandal-hit trust
Clive Flashman posted a news article in News
Inspectors raise ‘serious concerns’ about medical wards and emergency care at Shropshire NHS trust A patient bled to death on a ward at Shrewsbury and Telford Hospitals Trust after a device used to access his bloodstream became inexplicably disconnected, The Independent has learnt. The incident came to light as new concerns arose about quality of care at the Shropshire trust, with the Care Quality Commission (CQC) warning of “serious concerns” about its medical wards and emergency department following an inspection last month. Although the report from the inspection has not yet been published, it is understood that the trust has been served with a legal notice by the regulator to comply with more than a dozen conditions. It remains in special measures following the inspection and is rated inadequate overall. See full article in The Independent here -
News Article
Patient deaths prompt ambulance chiefs to look for alternative defibrillators
Patient Safety Learning posted a news article in News
Ambulance chiefs are looking at alternative defibrillators after coroners highlighted confusion over how to correctly use their existing machines. London Ambulance Service (LAS) Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy. Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting. The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later. The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion. But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered. Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays. Read full story (paywalled) Source: HSJ, 10 August 2020 -
Content ArticleAmong the results reported by the Scan4Safety demonstrator sites, were: the release of 140,000 hours of clinical time back to patient care non-recurrent inventory reductions of £9m recurrent inventory savings worth nearly £5m across the six trusts.
-
News Article
Investigation launched into safety of maternity equipment used in NHS
Clive Flashman posted a news article in News
A national investigation has been launched into the equipment used by NHS staff to monitor babies heart rates during labour because of concerns they could be contributing to deaths and disabilities. The independent Healthcare Safety Investigation Branch (HSIB), which investigates systemic safety risks in the NHS, has opened an inquiry after reviewing hundreds of maternity incidents. It found equipment used to record cardiotocographic (CTG) traces were linked to 138 maternity investigations since 2018 with more than 238 separate findings referencing the use of CTG as a factor in the error. Read the full article here -
Content ArticleBetween April 2008 to March 2017, procedure data from the UK NHS confirmed that 100,516 patients had a mid-urethral tape procedure, while only 1195 patients had a non-tape SUI procedure. Although the 2013 national guideline from The National Institute for Health and Care Excellence (NICE) recommended that tape and non-tape SUI procedures be offered equally, 84 mesh tape procedures were performed for every 1 non-tape procedure over the 10-year period. Hundreds of patients recently engaged in litigation on the basis of lack of informed consent, particularly in offering alternatives to the mesh tape option. Little is known, however, about how patients choose among different treatment options for SUI and there are no validated patient decision aids (PDAs) in this context. PDAs have been shown to increase patient knowledge, clarity about their own values and accuracy of risk perceptions regarding various management options. Women considering SUI surgery require up-to-date information on all common and available surgical procedures as well as support in their decision-making, tailored to their values and needs. Agur et al. on behalf of the NHS Ayrshire & Arran Continence Multidisciplinary Team designed and developed a novel SUI surgery patient decision aid (SUI-PDA) to help women in making a choice of treatment based on their own individual values. This study reports the development and validation of SUI-PDA as well as the initial evaluation of its usefulness in clinical practice for women considering SUI surgery.
-
News Article
MHRA's response to the Cumberlege report
Patient Safety Learning posted a news article in News
The Medicines and Healthcare products Regulatory Agency (MHRA) has published its response to the Independent Medicines and Medical Devices Safety Review. In its response, the MHRA said: “Today’s publication of the Independent Medicines and Medical Devices Safety Review is of profound importance for the MHRA, since the safety of the public is our first priority." "We therefore take this report and its findings extremely seriously. Throughout the Review’s work we have listened intently to the many distressing experiences of women and their families. We will now carefully study the findings and recommendations of the Report. We recognise that patient safety must be continually protected and that many of the major changes recommended by the Review cannot wait. We are therefore making changes without delay to ensure that we listen to patients and involve them in every aspect of our work. We are already taking steps to strengthen our collaboration with all bodies in the healthcare system and will strive to ensure that, working with these other bodies, the safety changes we advise are embedded without delay in clinical practice. We wholeheartedly commit to demonstrating to those patients and families who have shared their experiences during the Review, and anyone else who has suffered, that we have learned from them and are changing and improving because of what they have told us. We are determined to put patients and the public at the heart of everything we do." Read full statement Source: GOV.UK, 8 July 2020 -
News ArticleFormer health secretary Jeremy Hunt has warned ministers not to let the Cumberlege review “gather dust on a shelf”. The chair of the Commons Health and Social Care Committee told The Independent it was vital action was taken to implement the recommendations. Mr Hunt, who made patient safety a key focus of his tenure as health secretary, backed the idea of an independent patient safety commissioner that would be outside the NHS and have powers to advocate for patient issues. Mr Hunt said: “This report should be a powerful wake-up call that our healthcare system is still too closed, defensive and focused on blame rather than learning lessons. It’s truly harrowing to hear of all the women and families who live with permanent anguish because of these medicines and devices, and it has clearly taken too long for their voices to be heard.” “The NHS is one of the safest health systems in the world, and we’re all rightly in awe of our frontline heroes. But in healthcare getting it right ‘most’ times isn’t good enough because the exceptions wreak lifelong devastation on families. So we must not allow this seminal report to gather dust on a shelf: lessons must be learnt once and for all.” Read full story Source: The Independent, 8 July 2020
-
News Article
Lives ruined as damage viewed as 'women's problems'
Patient Safety Learning posted a news article in News
Many lives have been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm, says a review. More than 700 women and their families shared "harrowing" details about vaginal mesh, Primodos and an epilepsy drug called sodium valproate. Too often worries and complaints were dismissed as "women's problems". It says arrogant attitudes left women traumatised, intimidated and confused. June Wray, 73 and from Newcastle, experienced chronic pain after having a vaginal mesh procedure in 2009. "Sometimes the pain is so severe, I feel like I will pass out. But when I told GPs and surgeons, they didn't believe me. They just looked at me like I was mad." The chairwoman of the highly critical review, Baroness Julia Cumberlege, said the families affected deserved a fulsome apology from the government. She said: "I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself." Read full story Source: BBC News, 8 July 2020 -
Content Article
-
News Article
DHSC tells care homes to destroy batch of COVID-19 tests over safety fears
Patient Safety Learning posted a news article in News
Care homes have been ordered to destroy a batch of faulty COVID-19 test kits after it was discovered that the swabs could break off while being used to gather samples from residents’ tonsils and noses. Care home managers were told on Sunday not to use the tests because they had “brittle stems at risk of snapping”. The kits were manufactured by Citotest, a company based in China, and were distributed by the government’s COVID-19 care home testing programme. It is tasked with providing tests for all staff and residents in care settings, not just people displaying symptoms. The affected batch should be destroyed or kept in a safe area clearly marked with warnings not to use them, officials said, adding that the problem emerged on Saturday and they were working as quickly as possible to resolve it. The Department of Health and Social Care (DHSC) said the batch could have contained tens of thousands of tests and that a complaint had been raised with the manufacturer, with whom discussions were ongoing. “We are aware of an issue with one batch of swab sticks which are being replaced where needed but this does not affect any tests, or the results of tests, previously taken,” a DHSC spokesperson said. “Testing is unaffected and people should still arrive for their booked tests.” Read full story Source: The Guardian, 15 June 2020 -
Content Article
-
Content ArticleSome aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients.
-
Content Article
-
News Article
New face cover for cancer test patients to stop COVID-19 spread
Patient Safety Learning posted a news article in News
Surgeons have invented a new device to make it safer to diagnose some cancers during the coronavirus pandemic. Most nose and throat investigations have been cancelled due to increased risks of medics contracting COVID-19 via patients' coughs and sneezes. Two consultants have developed a device that clips over patients' masks and protects front-line workers. The West Midlands-based doctors want to raise £50,000 they say is enough to make devices for use across the NHS. Chris Coulson, a consultant ear, nose and throat surgeon at University Hospitals Birmingham NHS Foundation Trust, said procedures involving an endoscope to examine the nose or throat were known to put clinicians at a significantly increased risk of contracting coronavirus. "When clinicians carry out a nasendoscopy it can make patients cough, sneeze, and splutter - which risks spreading the virus to doctors, nurses and therapists," he said. His company endoscope-i Ltd, co-founded with Ajith George, a consultant head and neck surgeon at University Hospitals North Midlands, has now developed the SNAP. It clicks on to a conventional surgical mask, creating a hole through which the clinician can pass an endoscope directly into a patient's nose. A valve means, despite there being a hole, any coughs, sneezes or splutters are caught within the mask. Mr George said: "If we can raise the money needed to produce the devices, we can keep looking after patients and ensure that diagnosis and treatment is not delayed." Read full story Source: BBC News, 11 May 2020 -
Content Article
-
News ArticleNHS staff say they are being put at risk during the coronavirus outbreak because of a lack of protective gear. One doctor told the BBC that frontline healthcare workers felt like "cannon fodder" as they do not have access to equipment such as face masks. Health workers also expressed concerns that not enough of them were being tested for the virus. Prime Minister Boris Johnson said the UK had "stockpiles" of personal protective equipment (PPE). But Dr Samantha Batt-Rawden, from lobbying group the Doctors' Association, said she had heard from doctors who had not got access to PPE - or it had expired or run out. "All these doctors are worried that that's increasing their likelihood of contracting the virus and then ultimately spreading it to patients," she said. Read full story Source: BBC News, 18 March 2020
-
Content Article
ECRI - Top 10 Patient Safety Concerns 2020
Claire Cox posted an article in Maternity
ECRI’s list of patient safety concerns for 2020: 1. Missed and delayed diagnoses—Diagnostic errors are very common. Missed and delayed diagnoses can result in patient suffering, adverse outcomes, and death. 2. Maternal health across the continuum—Approximately 700 women die from childbirth-related complications each year in the U.S. More than half of these deaths are preventable. 3. Early recognition of behavioural health needs—Stigmatisation, fear, and inadequate resources can lead to negative outcomes when working with behavioural health patients. 4. Responding to and learning from device problems—Incidents involving medical devices or equipment can occur in any setting where they might be found, including ageing services, physician and dental practices, and ambulatory surgery. 5. Device cleaning, disinfection, and sterilisation—Sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and an associated annual cost of $3.3 billion. 6. Standardising safety across the system—Policies and education must align across care settings to ensure patient safety. 7. Patient matching in the EHR—Organisations should consistently use standard patient identifier conventions, attributes, and formats in all patient encounters. 8. Antimicrobial stewardship—Over prescribing of antibiotics throughout all care settings contributes to antimicrobial resistance. 9. Overrides of Automated Dispensing Cabinets (ADC)—Overrides to remove medications before pharmacist review and approval lead to dangerous and deadly consequences for patients. 10. Fragmentation across care settings—Communication breakdowns result in readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and dissatisfaction. -
Content ArticleKey learning points If the patient had been more closely observed it is likely cardio-respiratory arrest and subsequent hypoxic brain injury could have been avoided. Effective procedures for nurse communication, effective handover and observation of critically unwell patients in intensive care and high dependency units are very important to safe patient care. Bedside and remote monitoring equipment provide vital information to staff and should be properly maintained and replaced where necessary.
