ANZCA Bulletin June 2012 - final.pdf - Australian and New Zealand ...

Quality and safetycontinuedECRI alertsThe ECRI Institute is a non-profitorganisation that issues alerts fromfour sources: the ECRI InternationalProblem Reporting System, productmanufacturers, government agenciesincluding the US Food and DrugAdministration (FDA) and agencies inAustralasia, Europe and the UK as wellas reports from client hospitals.Some alerts may only involve singleor small numbers of cases, there is nodenominator to provide incidence andthere is not always certainty about theregions where the equipment is supplied.This section can only highlight someof the alerts that may be relevant. It is theresponsibility of the hospitals to follow upwith the manufacturer’s representativesif they have not already been contacted.Flow rate inaccuracy in Bayer MRtubing sets used with Continuumpumps (designed for use in MRIenvironments)Bayer MEDRAD Continuum MR infusionsystem tubing may exhibit variations inflow when used with Continuum infusionpumps. There has been a recall of thetubing and continuum pumps that havebeen calibrated with the tubing.Accurate delivery of criticalmedications in the MR environment isdifficult without appropriate pumps.Although it is possible to the use“regular” volume or syringe pumps sittingoutside the field and to connect to thepatient with several extension tubing sets,the compliance and length of tubing mayaffect rate accuracy and responsivenessto rate changes. Other MR conditionalpumps are available.Cassette test failure alarm on loadingof Hospira PlumSet Administration Setonto pumpHospira has recalled its 104-inch LifeshieldPrimary PlumSet Administration Sets.A cassette failure alarm may occur whenthese sets are loaded onto the pump,possibly due to failure in welding of thecassettes. The cassette cannot and shouldnot be used. The main potential adverseoutcome is a delay in administration ofthe required therapy.Luer connection leak in COBE spectrablood warmer systems (Caridian BCT)If specific directions are not followed,a leak may occur at the return luerconnection to an elevated blood warmerpotentially resulting in air entrainmentinto the system.Caridian BCT has inserted anaddendum to the labelling: “Whenconnecting a blood warmer tubingset to the return line, ensure that thetubing connection is tight. Put the luerconnection no higher than 50cm abovethe return access to prevent the possibilityof air entering the tubing”.Dr Phillipa HoreCommunications and Liaison PortfolioQuality and Safety CommitteeGeneral alertsCoronial alertAn Australian coroner investigating thedeath of a patient undergoing repair of aclavicle recently highlighted his findingsthat a screw had been inadvertentlyinserted into the right subclavian vein.There was considerable haemorrhage,which was aggressively managed, butthe patient did not improve and couldnot be resuscitated. The possibilityof concomitant air embolism was alate diagnosis, probably due to theconcentration of the surgical andanaesthetic team on managing thehaemorrhage.While not critical of the team, thecoroner sought to highlight the possibilitythat whenever a large vessel is perforated,other causes of refractory resuscitationsuch as air embolism should beconsidered as well as the hypovolaemiathat results from massive haemorrhage.Dr Patricia MackayCommunications and Liaison PortfolioQuality and Safety CommitteeGreen armbands in ophthalmicsurgeryAustralian anaesthetists should be awarepatients who have vitreo-retinal surgeryget a green wristband if they have had gasinstilled in the globe of the eye.The band remains on until the surgeonconsiders the gas has completely gone,usually 4-6 weeks. The administration ofnitrous oxide under these circumstancesmay be a potential risk to the eye andshould be avoided.Safety of Anaesthesialatest reportANZCA’s Safety of Anaesthesia, a reviewof anaesthesia-related mortality reportingin Australia and New Zealand 2006-2008is now available on ANZCA’s websiteunder resources. A web booklet versionwill be available soon and publicised inan upcoming ANZCA E-Newsletter. Forqueries please contact ANZCA’s Qualityand Safety Officer on qs@anzca.edu.au.44 ANZCA Bulletin June 2012