Medical device display errors
46 items
2 sources
Clinician misinterpretation of unrecordably low critical values displayed on medical devices (e.g., glucose as '---↓').
Cross-Source Insight
Medical device display errors has been flagged across 2 independent accountability sources:
1 inquiry rec
45 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (45)
Margaret Grimsley
Concerns: The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it is standard practice.
Response: The Trust disputes the necessity of using an upper oxygen alarm, explaining that although functionality exists, it is not used as the greatest risk is low blood oxygen, focusing instead …
Responded
Melanie Walker
Concerns: Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
Response: The Greater Manchester ICB has reconfigured heart monitor alarms so that 'ECG leads off' alerts will visually flash and re-alarm audibly every three minutes if not reconnected, whereas previously they …
Response: Philips reset the 'ECG Leads Off' alarm at the specific hospital to its factory default medium priority. However, Philips disputes the need for wider changes to their product's default settings, …
Response: The Department noted that Philips has already issued a Field Safety Notice for its IntelliVue Patient Monitors, clarifying that alarm functions are user-reconfigurable and must be confirmed as 'alarm on'. …
Responded
Kathleen Gregory
Concerns: A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Responded
Jake Lawler
Concerns: Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed cardiac conditions in children.
Responded
Sybil Morgan-Gray
Concerns: Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical patient conditions.
Responded
June Liddell
Concerns: Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail to identify component wear and tear.
Responded
Michael Walton
Concerns: Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of appropriate medical equipment.
Responded
Ben Harrison
Concerns: Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure medical emergencies.
Responded
Thomas Wakefield
Concerns: Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.
Responded
Lauren Smith
Concerns: Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. Inadequate qualitative training assessment and lack of post-incident training pose a significant patient safety risk.
Responded
Devon Turner
Concerns: Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents to critical oxygen drops.
Responded
Jade Revell
Concerns: The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of a scroll feature, and inability to prominently flag out-of-range values.
Responded
Van Tuyen
Concerns: Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
Responded
Mary Land
Concerns: The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking mechanism is needed to prevent inadvertent disconnections.
Responded
Diana Reay
Concerns: Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.
Overdue
Ann Geraghty
Concerns: Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a solution.
Responded
Chimezie Daniels
Concerns: CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.
Responded
Kishorkumar Patel and Kofi Aning
Concerns: The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This lack of simplification and standardisation risks incorrect filter usage and patient safety.
Responded
Andrew Cook
Concerns: Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, and various synonyms.
Responded
Peter Hussey
Concerns: An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its reduced bore size. This caused inadequate drainage, and the product is still misleadingly promoted.
Overdue
Stephen Oakes
Concerns: Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. Hospital evaluation was insufficient, and staff lacked training on product changes and alternative actions.
Overdue
Don Fernandes
Concerns: Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce x-ray exposure led to confusion about the need for confirmation, risking tube misplacement.
Responded
Leslie Harris
Concerns: The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.
Responded
Ivan O’Neill
Concerns: Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.
Overdue
Susan Warby
Concerns: Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.
Responded
Doris Clark
Concerns: A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Overdue
Jeanette Robinson
Concerns: An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.
Responded
Norman Pirie
Concerns: A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.
Responded
Freddie Dobinson-Evans
Concerns: A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant consequences for other children.
Overdue
Donald Till
Concerns: Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.
Responded
Peter Cotter
Concerns: Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting the need for a review of head injury recognition protocols.
Responded
Glenys Pollitt
Concerns: Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.
Responded
Joseph De Pellergrino-Farrugia
Concerns: The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence and prevent operation.
Overdue
James Hedge
Concerns: Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
Responded
Geoffrey Parry
Concerns: Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Responded
Dilys Jenkins
Concerns: Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
Overdue
Brian Marks
Concerns: PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.
Responded
James Fyfe
Concerns: The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA failed to escalate this known hazard to other hospital trusts.
Responded
Gaenor Moore
Concerns: Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training regarding equipment setup.
Responded
Jackson Mitchell
Concerns: The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.
Overdue
Marjorie Phillips
Concerns: The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.
Responded
Archie Hames
Concerns: The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with similar devices.
Overdue
Arthur Brockett-Deakins
Concerns: Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.
Responded
Kenneth Smalley
Concerns: A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or hospital-wide review for similar equipment.
Response: Wrightington Wigan and Leigh NHS Foundation Trust has inspected all operating tables, carried out repairs, and implemented a more robust training system for theatre staff. Visual checks of operating table …
Overdue
Sangeerth Girirathan
Concerns: Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in a cardiac arrest.
Pending