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HSIB report (Foetal Monitoring) and new investigation Blood Transfusions for neonates

The Healthcare Safety Investigation Branch (HSIB) have just issued their report into their investigations into suitability of equipment used for continuous foetal heart rate monitoring. In addition they have also launched a national investigation into the safety risk of delayed administration of neonatal blood transfusions. Specifically, the investigation explores communication between multidisciplinary teams of risk factors …

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Interference from apple mobile phones and other devices

Apple has recently shared recent news that under certain conditions, magnets and electromagnetic fields may interfere with medical devices. For example, implanted pacemakers and defibrillators may contain sensors that respond to magnets and radios when in close contact. To avoid any potential interactions with these types of medical device, keep your Apple product a safe …

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Medical devices sterilised by Steril Milano; 88 companies known to be involved

The MHRA has been advised of 88 medical device manufacturers for whom Steril Milano provided sterilisation services.  Additional companies, that are part of the supply chain for the affected manufacturers, have also been identified. However, for the majority of devices the risk to patients is low. The MHRA is not aware of adverse incidents reported …

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The importance of flushing IV lines and its associated risks

Our colleagues at NIVAS (National Infusion and Vascular Access Society) have shared their latest guidance on line flushing for IV administration and raise a number of important risks for all staff involved in the use of infusion pumps, IV bolus and gravity infusions. There is also the potential risk of bolus effect or incompatibilities with the residual medicine in infusion set, if the same set is subsequently used to administer other infusions. In the first instance infusion sets should NOT be continuously used for the administration of different medicine solutions, a new infusion set should be used for each new medicine. Infusion sets can be used continuously for fluid infusions such as sodium chloride 0.9% in line with local policy.

To avoid unintended bolus/push administration of medicine from the dead space in an infusion set, care should be taken to ensure the rate of administration of a flush or subsequent infusion is the same as the rate of administration of the medicine. An incident reported to the NRLS describes an infusion of potassium chloride in sodium chloride 0.9% that was changed for a bag of Hartmann’s solution. Because the Hartmann’s solution was infused faster than the potassium chloride infusion it replaced, the patient received an unintended push of the residual potassium solution.

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