Healthcare Alerts
The healthcare alerts featured are issued by either the NPSA or MHRA.
We are publishing them to improve the awareness of important issues in clinical practice and product use.
Product recall notice
Vygon has issued the following product recall notice on Octopus three lumen with anti-reflux valves. It has been identified that, due to a production error, there may be a number of products of batch number 080411AE, which may incorporate an anti-syphon valve instead of an anti-reflux valve.
Needle-free intravenous connectors
The MHRA issued MDA/2004/005 in January 2004 to raise awareness of incompatibility between some needle-free connectors and Luer tips of pre-filled syringes.
The MHRA continues to receive reports of damage to the needle-free connector and/or to the pre-filled syringe where force has been used to connect incompatible devices together. In some cases fragmentsmay block the syringe outflow. Such damage has resulted in a delay in administering therapy during the resuscitation of patients.
Reducing the harm caused by misplaced nasogastric feeding tubes
PSA/002
This Alert updates and strengthens Patient Safety Alert 05 (Reducing the harm caused by misplaced nasogastric feeding tubes) and is based on national learning since then.
Safer spinal, epidural and regional devices
PSA/001
There have been fatal cases where intravenous medicines have been administered by the spinal (intrathecal) route, and where epidural medicines have been administered by the intravenous (vein) route. There is also the potential for medicines intended for regional anaesthesia to be administered by the intravenous route, with fatal outcomes.
Risk of back-tracking when an IV line has multiple access ports
MDA/2010/073
The MHRA continues to receive reports of incidents involving intravenous (IV) extension sets with multiple ports. These incidents have led to serious consequences e.g. patients receiving an inadvertent bolus of anaesthetic agent due to back-tracking, resulting in respiratory arrest.
Promoting safer measurement and administration of liquid medicines
Patient Safety Alert 19
The National Patient Safety Agency (NPSA) is advising healthcare organisations on how the design of medical devices and the methods used to measure and administer oral liquid medicines* can improve patient safety.
