Adverse transfusion events
February 18, 2010
Intravenous news: InfectionControlToday.com report “The Centers for Disease Control and Prevention (CDC) has Read more
Gentamicin errors
February 9, 2010
Intravenous news: NPSA report “Patient safety incidents have been reported involving administration of gentamicin at the Read more
Q-Syte Nexiva recall extended
February 8, 2010
Intravenous products: BD has voluntarily executed a product recall of certain lots of BD Q-Syte™ Luer Access Devices Read more
Huber needle alert
January 26, 2010
Intravenous news: The U.S. Food and Drug Administration today announced a Class I recall of Exel/Exelint Read more
Parenteral syringe oral drug error
January 10, 2010
Intravenous news: The FDA report “A recent report by the Institute for Safe Medication Practices says that despite past Read more
Q-Syte needlefree alert
November 23, 2009
Intravenous news: BD has received reports of air leaking into infusion lines through the BD Q-Syte needlefree IV connector. This may Read more
Reusing single-use IV supplies
October 6, 2009
Intravenous news: Broward Health report “Broward General Medical Center is reviewing one nurse’s practice Read more
CareFusion IV pump alert
October 5, 2009
Intravenous products: CareFusion is alerting healthcare professionals about a number of safety problems with several models Read more
Hospira IV pump alert
October 5, 2009
Hospira, Inc. has issued an alert about a number of the company’s medical devices that have defective AC Read more
Heparin safety changes
October 2, 2009
Intravenous news: PRnewswire.com report “The U.S. Food and Drug Administration today alerted health care Read more
Promethazine FDA Boxed Warning
September 26, 2009
Intravenous news: FDA is requiring a Boxed Warning for promethazine hydrochloride injection, USP products to better Read more
Topical epinephrine injection death
September 1, 2009
Intravenous news: FDA report “The Institute for Safe Medication Practices (ISMP) recently cited a report from the ISMP Canada Safety Bulletin about the death of a patient who was accidentally injected with topical epinephrine. The attending surgeon and nurse mistakenly thought the syringe they were using contained lidocaine with epinephrine 1:100,000.
ISMP noted an earlier case in which a child died from cardiac arrest after his ear was infiltrated with a syringe containing epinephrine 1:1,000 that had been filled from an open cup. The physician mistakenly assumed that the solution in the cup contained lidocaine with epinephrine 1:100,000.”
Click here for the full report.
Insulin pump alert from FDA
September 1, 2009
Intravenous products: FDA report “In July, Medtronic recalled certain infusion sets which are used with the company’s Mini-Med Paradigm insulin pumps to deliver insulin to diabetic patients. Because of a manufacturing error, the vents on these sets may clog and then fail to equalize the air pressure in the reservoir compartment with the surrounding atmosphere. If this happens, the pump could deliver too much or too little insulin to the patient, and that could lead to serious injury or death.”
Click here for the full report.
Infusion error deaths
August 18, 2009
Intravenous news: ISMP.org report “ISMP recently learned about the tragic deaths of two 6-year-old children stemming from severe postoperative hyponatremia. The fatal events occurred at two different hospitals. In at least one of these cases, it is clear that the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in acute hyponatremia secondary to free water retention (also called water intoxication, which is described below). Postoperative children are at high risk for developing hyponatremia, and many fatalities from this disorder have been reported in the literature. When the serum sodium concentration rapidly falls below 120 mEq/L over 24 to 48 hours—as in the two events described below—the body’s compensatory mechanism is often overwhelmed and severe cerebral edema ensues, resulting in brainstem herniation, mechanical compression of vital midbrain structures, and death.”
Click here for the full article.
Intravenous interaction
July 1, 2009
Intravenous news: The FDA has issued an update on earlier recommendations about the interaction between the antibiotic ceftriaxone and intravenous products that contain calcium.
“In certain circumstances, this interaction can cause dangerous precipitates to form. Ceftriaxone is sold as Rocephin and also as a generic. Products that contain calcium include Ringer’s solution, Hartmann’s solution and parenteral nutrition formulations that contain calcium. FDA had previously recommended that ceftriaxone and calcium-containing IV products not be administered within 48 hours of one another for patients of all ages. This has now changed. It is no longer necessary to wait 48 hours in patients over 28 days old, provided that certain precautions are followed. And FDA is still stressing that ceftriaxone must not be used in neonates if they are receiving or will receive calcium-containing IV products.
Ceftriaxone and products that contain calcium may now be administered sequentially to patients older than 28 days of age, as long as the infusion lines are thoroughly flushed between infusions with a compatible fluid. However, ceftriaxone must not be administered simultaneously with intravenous calcium-containing solutions through a Y-site. FDA also continues to advise practitioners not to reconstitute or mix ceftriaxone with products that contain calcium.
There are no data on whether ceftriaxone might interact with calcium-containing products that are given orally. It’s also not clear whether intramuscular ceftriaxone might interact with calcium-containing products, either IV or oral”.
Click here for the full report from the FDA.
FDA insulin pump alert
July 1, 2009
Intravenous products: The July FDA Patient Safety News Alert describes that “Disetronic Medical Systems is notifying healthcare professionals and patients about a possible defect with the some of the company’s ACCU-CHEK Spirit insulin pumps. The defect can cause the “up” and “down” buttons on these pumps to stop working, either completely or intermittently. These buttons are used to change the pump programming or to administer additional insulin through a bolus delivery. So if they do not work, pump users may not be able to change any of the pump’s programmed settings.
When the buttons are pushed, the pump normally responds with a confirmation signal: a sound, a vibration, or both. If the buttons stop working, the signal will not occur, and the pump display will not change. If pump users cannot confirm that a change was made, they should disconnect the pump and switch to a back-up pump or other insulin delivery method. Then they should immediately contact the company’s hotline to get a replacement pump. If the buttons on the pump continue to work, the company says the pumps can still be used, but users should make sure the “up” and “down” buttons are working, by verifying that they get a confirmation signal after each pump operation”.
For more information call the ACCU-CHEK Spirit hotline. That number is 1-800-778-5095.
Click here for the full FDA alert.
Possible heparin deaths
May 11, 2009
Intravenous news: The Chicago Tribune reports ‘Baxter International Inc. said medical care providers at a hospital in Delaware and U.S. health officials are investigating whether the deaths of two patients are linked to a brand of heparin blood thinner Baxter sells in intravenous bags.
The U.S. Food and Drug Administration said the situation “appears to be an isolated incident,” agency spokeswoman Karen Riley said this afternoon.
Use of Baxter’s heparin, a diluted form in pre-mixed bags used for a variety of blood thinning purposes, has been suspended by officials at Beebe Medical Center in Lewes, Del. since Friday. Adverse reactions were reported in five patients who had problems that included internal bleeding in the brain”.
Click here for the full news story.
FDA insulin pen alert
March 21, 2009
Intravenous news: News-Medical.net report that the “U.S. Food and Drug Administration has issued an alert to health care professionals reminding them that single-patient insulin pens and insulin cartridges should not be used to administer medication to multiple patients due to the potential risk of transmitting blood-borne pathogens such as HIV and the hepatitis viruses.
Insulin pens are pen-shaped injector devices that contain a disposable needle and either an insulin reservoir or an insulin cartridge. The devices typically contain enough insulin for a patient to self-administer several doses of insulin before the reservoir or cartridge is empty. All insulin pens are approved only for single-patient use (one device for only one patient).
The FDA is aware of incidents at two undisclosed hospitals involving more than 2,000 people in which the cartridge component of the insulin pens were used to administer insulin to multiple patients, although the disposable needles were reportedly changed among patients”.
Click here for the full story on News-Medical.net
Baxter IV pump alert
March 11, 2009
Intravenous products: Baxter International Inc. has found more problems with its long-troubled “Colleague” intravenous fluid pumps, including software glitches the company needs to fix and user problems it has advised customers to avoid.
The Deerfield, Ill., company sent a letter to customers on Jan. 23, a day after its fourth-quarter earnings call, to highlight the newfound issues with its entire roster of 275,000 Colleague pumps around the world, including pumps the company issued during remediation efforts to fix other problems. Colleague pumps were first pulled in 2005 amid a host of problems and defects linked to some deaths.
The latest problems came under the spotlight Wednesday when Baxter said the U.S. Food and Drug Administration had assigned a “Class 1″ recall status to the matter, which is the agency’s most serious recall classification.
Click here to view the full news item on CNNMoney.com
Alaris IV pump alert
March 11, 2009
Intravenous products: This Safety Alert informs you about a potential risk when the Alaris® PCA module (model 8120) is used with the Alaris® PC Unit (model 8000 and model 8015) with software versions 8 through 9.1. The Alaris® PCA module can potentially infuse above or below the intended infusion dose.
Click here to view the full safety notice.
IV particles lead to drug recall
February 25, 2009
Intravenous news: Health Canada, the federal agency that regulates the country’s healthcare delivery, is recalling lots of a drug used to treat iron and aluminum toxicity in dialysis patients due to the possibility of tiny particles forming after the drug is prepared for intravenous administration.
Health Canada said it is working with manufacturer Hospira Healthcare Corp. in recalling certain lots of Desferrioxamine Mesilate for Injection, which treats acute or chronic iron toxicity and chronic aluminum overload in dialysis patients with end-stage renal disease. The formation of particles in the affected lots might produce cloudiness after preparation. These particles can block small blood vessels after injection.
The following are being recalled: Lot U072231AA in a 500-mg format and Lot U102237AA in a 2-g format. The lot number is on the label of the carton as well as on the vial.
Click here for the full story.
IV extension set alert
January 21, 2009
The MHRA have issued an alert that concerns the Sae-Flo MD extension set with Y-connector (lot number 80623/1 only). Manufacturer: Wescott Medical Ltd. Product code: WEPCA200AY. NHS Supply Chain code: FSB025 (England only).
A number of devices from this lot have been reported to leak at the connection between the anti-siphon valve (female Luer) and the tubing. Very few of the leaks were detected during priming. This can lead to inadequate pain relief or treatment of patients.
Please click here to view the Medical Device Alert for further information.
Intravenous fluid alert
December 11, 2008
Hospira, Inc., a global specialty pharmaceutical and medication delivery company, is following up on a nationwide voluntary recall issued Sept. 18 of one lot (lot number 65-620-FW, expiration date May 1, 2010, NDC 0409-7902-09) of 20 mEq Potassium Chloride in 5% Dextrose and 0.45% Sodium Chloride Injection, USP in 1000 mL flexible plastic containers because a small number of the containers may be incorrectly labeled with a bar code for 5% Dextrose Injection, USP (NDC 0409-7922-09). The incorrect bar code could lead to a medication error resulting in the wrong drug being delivered to a patient if a bar code system is used to confirm the medication. Potential adverse events related to an error of this type include electrolyte imbalance, cardiac dysfunction, gastrointestinal disturbances, paresthesia and mental confusion.
The product contains 20 mEq Potassium Chloride in 5% Dextrose and 0.45% Sodium Chloride. The product name and National Drug Code (NDC) number printed on the container are correct. The affected lot was shipped to U.S. customers between July 2008 and September 2008. No other lots are affected by this recall.
Click here to read the full news release.
Snapped needles
November 14, 2008
China said on Friday it had recalled a batch of disposable medical needles after one snapped when inserted into an infant’s vein. Health organizations were ordered to stop using the needles, made by a Shanghai-based firm, after tests on another six from the same batch showed they all broke easily. The incident with the needle was reported by a maternity center in southeastern Guangdong province in mid-October.
Click here to view the full story.
Infection control for dialysis
November 4, 2008
To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, CDC recommends that all single-use injectable medications and solutions be dedicated for use on a single patient and be entered one time only. Medications packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared in a clean area separate from potentially contaminated items and surfaces. In hemodialysis settings where environmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area. Proper infection control practices must be followed during the preparation and administration of injected medications. This is consistent with official CDC recommendations for infection control precautions in hemodialysis and other health-care settings.
Click here for the full news item on JAMA.
Vivitrol injection site reaction
October 31, 2008
FDA is alerting healthcare professionals about the risk of serious reactions at the injection site among patients treated with Vivitrol (naltrexone). Vivitrol is administered intramuscularly to treat alcohol dependence.
FDA has received nearly 200 reports of injection site reactions, including cellulitis, induration, hematoma, abscess, sterile abscess and necrosis. Some patients needed surgical intervention. The risk may be increased if the drug is injected subcutaneously or accidentally into fatty tissue.
Practitioners using Vivitrol should use only the specially designed needle that comes with the drug, and take care not to inject the material intravenously, subcutaneously, or into fatty tissue. The special needle may not be long enough to reach muscle tissue in patients with significant gluteal fat. Healthcare providers should consider alternative treatment in these cases.
Patients who develop pain, swelling, bruising, itching or redness that does not improve within two weeks should be instructed to report this, and should be referred to a surgeon.
Click here for the FDA report.
TRALI following IVIG
October 7, 2008
Transfusion-related acute lung injury (TRALI) is a clinical syndrome that presents as acute hypoxemia and noncardiogenic pulmonary edema during or within 6 hours after blood transfusion.
Health Canada received a report of a 38-year-old man who had received Gamunex for the treatment of streptococcal thoracic cellulitis, which had also required débridement. Two hours and 50 minutes into the infusion, after receiving 57.5 g of Gamunex, the patient experienced hypotension and dyspnea. The infusion was stopped. The results of a chest radiograph were compatible with a diagnosis of TRALI. The patient was transferred to the intensive care unit, where he required intubation. The result of an anti-human leukocyte antigen test was pending at the time of reporting.
Click here for the full Canadian Adverse Reaction Newsletter.
Infusion pump malfunction
October 4, 2008
FDA informed healthcare professionals of the possibility that x-rays used during CT examinations may cause some implanted and external electronic medical devices to malfunction. Most patients with electronic medical devices undergo CT scans without any adverse consequences. However, the Agency has received a small number of reports of adverse events in which CT scans may have interfered with electronic medical devices, including pacemakers, defibrillators, neurostimulators, and implanted or externally worn drug infusion pumps.
Click here for the full FAD announcement.
IV catheter obturator alert
September 7, 2008
Due to a manufacturing problem, there may be cracks and holes in the packaging of some obturators for Venflon™ cannulae, which could compromise sterility. The obturator protects the inner lumen of the catheter from coagulation and thrombus formation after discontinuation of infusion.
The device in question is Venflon™ IV cannula obturator manufactured by BD. Product code numbers 394252 and 394253. Various lot numbers.
Click here for the MHRA alert.
Clean hands save lives
September 7, 2008
On the 2nd September 2008 the National Patient Safety Agency (NPSA) has reissued its Alert on hand hygiene to reinforce its importance as a significant factor in reducing infection in health.
The guidance has been produced by the NPSA and applies to all NHS staff in England and Wales who have direct contact with patients.
Speaking of the “Clean Hands Save Lives” alert, Martin Fletcher, Chief Executive of the NPSA said:
“The patient safety alert highlights the need for all healthcare staff to clean their hands at the point of care – that is, the patient’s immediate environment where treatment takes place – as this is when there is the greatest risk of transferring infection. In hospitals, the point of care will usually be around the patient’s bed, while in other settings this could be a treatment room, cot, chair, ambulance or the patient’s home.”
The NPSA recommends the use of alcohol handrub only on non-soiled hands as it is effective and quick to use. If hands are visibly dirty or if the patient has been experiencing vomiting or diarrhoea then the healthcare staff must wash their hands with liquid soap and water.
From 1 November 2003 to 15 July 2008 there have been 379 patient safety incidents reported to the NPSA involving alcohol handrub. Although the majority of these resulted in no or low harm the NPSA believes that these risks could be managed if NHS trusts followed their recommendations on where the handrub dispensers should be placed.
“The National Patient Safety Agency has always said that alcohol handrub is most effective when the dispensers are installed at the point of care as this is when staff should be cleaning their hands to avoid spreading infection,” Martin Fletcher said. “In most cases this is at the foot of the patient’s bed, their bedside locker or their chair. We recommend staff use personal dispensers, particularly if they treat children or mental health patients, as this further minimises risk. Hospitals that install handrub dispensers away from the point of care, including along corridors or at ward entrances, must take the necessary safety and storage precautions”.
To coincide with the alert, which replaces guidance from 2004 and now includes best practice guidelines set by the World Health Organisation (WHO), the NPSA is hosting a summit today (2 September) at the UCL Institute of Child Health. The summit will highlight issues such as risk management and the international standard for hand hygiene products through a series of presentations by the WHO World Alliance for Patient Safety, Health Protection Agency, Department of Health and Welsh Assembly Government.
Local organisations remain responsible for making sure their healthcare staff comply with hand hygiene procedures, and the NPSA will review how the alert has been put into practice in April 2009.
Vincristine NPSA alert
August 13, 2008
The NPSA in the UK have reported on “…reports of serious incidents in hospitals outside of the UK in which doses of vinca alkaloids intended for intravenous administration have been administered by the intrathecal (spinal) route in error, updated advice has been issued to the NHS. The incidents include three cases where doses of vincristine had been diluted to 10ml and 20ml in syringes”.
IVTEAM has reported on one of these cases here.
The NPSA continue with “Previous guidance to the NHS in England and Wales was to dilute doses of vinca alkaloids to 10ml or greater in a syringe in order to reduce the risk of wrong route errors. This guidance needs to be updated following the learning from these incidents in other countries.
When vinca alkaloids are prescribed, dispensed or administered in adult and adolescent units:
• Doses in syringes should no longer be used.
• The prescribed dose should be supplied from the hospital pharmacy ready to administer in a 50ml minibag of sodium chloride 0.9% (for some brands of vinorelbine glucose 5% solution for injection may be used instead of sodium chloride 0.9%).
• The following warning should be prominently displayed on the label of ALL vinca alkaloid doses ‘For Intravenous Use Only – Fatal If Administered by Other Routes’.
• There should be judicious use of colour and design on the label, outer packaging and delivery bags to further differentiate minibags containing vinca alkaloids from other minibag infusions.
• The vinca minibag should be infused intravenously over 5 – 10 minutes and the patient closely monitored for signs of extravasation. Incidents of extravasation should be reported and shared via the National Extravasation Information Service (www.extravasation.org.uk).
• Chemotherapy policies and procedures should be amended to reflect these requirements.
• Staff should be alerted and trained to follow the new practice.
• Practice should be audited to ensure compliance with the revised safety procedure”.
Arterial line alert
August 12, 2008
The NPSA have reported “Arterial lines are routinely used in critical care areas for sampling arterial blood to measure blood gases, glucose and electrolytes.
Patients may be harmed if the wrong infusion is given to keep the line open or when poor sampling leads to delayed or inappropriate treatment.
The NPSA is aware of two deaths and 82 other incidents up to June 2008 where the wrong infusion fluid was attached to the arterial line. A further 76 incidents, including one case of serious harm, related to faulty sampling technique”.
Visit the NPSA for the full details.
Medical Device Alert MDA/2008/051
July 21, 2008
The MHRA have issued a medical device alert (MDA/2008/051) which concerns the Kimal safety fistula needle. Kimal is aware of the potential for the unintentional retraction of the cannula into the protection sheath, which can result in exsanguination. As a result, Kimal is recalling all lots of the device.
Revised EU monographs for heparin
July 19, 2008
The MHRA have reported a revision of European Pharmacopoeia monographs for heparin.
“Following increased reports of adverse events associated with heparin preparations in the United States of America and some European countries, the European Pharmacopoeia monographs for Heparin Calcium (0332) and Heparin Sodium (0333) have undergone rapid revision and implementation in order to strengthen the level of testing required for quality control.
The revised monographs were adopted by the European Pharmacopoeia Commission on 25 June 2008 and are expected to come into effect on 1 August 2008, pending a decision by the European Committee on Pharmaceuticals and Pharmaceutical Care (CD-P-PH).
The revised monographs will be published in European Pharmacopoeia Supplement 6.4 and supersede the relevant monographs published in the British Pharmacopoeia 2008 and 2009 editions.
Further information and copies of the monographs can be obtained from the EDQM (European Directorate for Quality of Medicines & HealthCare) website“.
Syringe disconnection alert
July 10, 2008
The MHRA have issued an alert warning of inadvertent syringe disconnection.
The issue is with procedure packs from various manufacturers which contain BD Medical Surgical Systems 2ml, 5ml and 10ml Plastipak Luer slip syringes.
The warning points to potential for the BD Luer slip syringes supplied in procedure packs to spontaneously disconnect or fail to maintain a secure connection to Luer fittings of other devices.
Click here for further information.
Potential infusion error
July 10, 2008
The MHRA have issued an alert warning of potential infusion device drug error when using the Smiths Medical Graseby Omnifuse and Omnifuse PCA syringe pumps.
The MHRA have warned of the possibility of patients being given an additional/unnecessary infusion when syringes are changed or infusions restarted when using DrugPro software. If the user selects – but does not confirm – a drug protocol from the drug protocol library and then resets/stops the pump, the previously infused volume will not be added to the ‘total volume infused’ display.
Click here for further information.
FDA update on heparin
July 6, 2008
The FDA have recently released a video update on the contaminated heparin issue.
Over the past several months, FDA has been alerting healthcare professionals and the public about medical products that may contain contaminated heparin, which has been associated with a number of serious adverse events. Here is an update and recommendations on this continuing issue.
If the video does not show click here.
MADRI conference on CRBSI
June 16, 2008
The Multidisciplinary Alliance Against Device-Related Infections (MADRI) hosted its eighth annual conference June 6-8, 2008 in Lansdowne, VA where leading infection specialists presented on a variety of topics, including research goals in epidemiology and infection control, legal perspectives on MRSA and catheter-related blood stream infections (CRBSIs).
“Driven by discussions around improving patient care and the prevention of device-related infections, the eighth annual MADRI conference was a huge success,” said Rabih Darouiche, M.D., VA distinguished service professor, Departments of Medicine (Infectious Disease Section) and Physical Medicine and Rehabilitation and director of Center for Prostheses Infection and MADRI founder. “In an open and educational atmosphere, experts across disciplines were able to discuss challenges associated with device-related infections and exchange ideas about prevention and improvement of patient care.”
One of the main themes of the conference was CRBSIs, a common nosocomial infection that develops when bacteria enter the blood stream through a central venous catheter (CVC).
Heparin flushes
May 28, 2008
The use of heparin has suddenly come under the spotlight in the UK. However, the reason for this attention is different to previous concerns in countries such as the US.
“An independent report has recently been published reviewing the circumstances of four patient safety incidents where an anaesthetist mis-selected sodium heparin 25,000 units in 5 ml (Monoparin) instead of sodium heparin 50 units in 5 ml (Hepsal) and administered the more concentrated solution in unlabelled syringes to four children. Thankfully the four children only experienced some temporary bleeding and otherwise are not reported to have suffered longer term harm. However, the potential for serious harm was recognised by the hospital trust” (NPSA 2008).
The NPSA state:
- Organisations should review local policies to minimise the use of heparin flush solutions in all devices, including complex central venous or arterial catheters. This should take into account the evidence reviewed by UK Medicines Information (UKMi) which confirms that heparin flushes should not normally be used to flush peripheral intravenous catheters.
- All flush solutions should only be administered following a prescription or patient group direction.
- Local policy and procedures should be reviewed to ensure risk with heparin flush solutions is minimised.
- Healthcare organisations should ensure that all relevant staff are made aware of this guidance and revised policy.
The Rapid Response Report from the NPSA can be viewed here and further support information can be viewed here.
HepC contamination – CDC full report
May 19, 2008
The Morbitity and Mortality Weekly Report (MMWR) from the CDC into “Acute Hepatitis C Virus Infections Attributed to Unsafe Injection Practices at an Endoscopy Clinic, Nevada, 2007″ has been published. The report is very thorough, it describes the investigation and highlights how the contamination may have occurred. Click here for the full report.
The CDC write “On January 2, 2008, the Nevada State Health Division (NSHD) contacted CDC concerning surveillance reports received by the Southern Nevada Health District (SNHD) regarding two persons recently diagnosed with acute hepatitis C. A third person with acute hepatitis C was reported the following day. This raised concerns about an outbreak because SNHD typically confirms four or fewer cases of acute hepatitis C per year. Initial inquiries found that all three persons with acute hepatitis C underwent procedures at the same endoscopy clinic (clinic A) within 35–90 days of illness onset. A joint investigation by SNHD, NSHD, and CDC was initiated on January 9, 2008. The epidemiologic and laboratory investigation revealed that hepatitis C virus (HCV) transmission likely resulted from reuse of syringes on individual patients and use of single-use medication vials on multiple patients at the clinic. Health officials advised clinic A to stop unsafe injection practices immediately, and approximately 40,000 patients of the clinic were notified about their potential risk for exposure to HCV and other bloodborne pathogens. This report focuses on the six cases of acute hepatitis C identified during the initial investigation, which is ongoing; additional cases of acute hepatitis C associated with exposures at clinic A might be identified. Comprehensive measures involving viral hepatitis surveillance, health-care provider education, public awareness, professional oversight, licensing, and improvements in medical devices can help detect and prevent transmission of HCV and other bloodborne pathogens in health-care settings”.
Click here for the full report.
Needlefree alert
March 18, 2008
The MHRA have issued an alert that describes how the septum of a needleefree device may remain recessed. Click here to view the alert.
The colour purple
March 12, 2008
Interest in high pressure, high flow PICC’s is growing. However, Deborah Bolton, IV Clinical Nurse Specialist from Brighton has questioned the colour of these devices. The NPSA issued a patient safety alert in 2007 that promoted the use of identifiable oral only compatible equipment. This was in response to… Read more
MHRA alert MDA/2007/089
December 21, 2007
The MHRA have recently published an alert to warn practitioners of the risk of back tracking when more than one IV line is connected through a single access point. I would hope when practitioners setup the IV plumbing they always consider the risk of backtracking and put actions/devices in place that will prevent this problem. View the document here.
Should NPSA alert include saline flushes
November 20, 2007
In March 2007 the NPSA issued a patient safety alert that looks at the issue of promoting safer injections. One of the key recommendations from the alert is for the NHS and the independent sector to “Undertake a risk assessment of injectable medicine procedures and products in all clinical areas to identify high risks, and develop an action plan to minimise them”.
Is it now the time to include saline flushes in this risk assessment… I hope so.
