Medical device display errors
Clinician misinterpretation of unrecordably low critical values displayed on medical devices (e.g., glucose as '---↓').
85 items
8 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
73match
Sybil Morgan-Gray
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.
Matched on
terms: display
PFD report
69match
Susan Warby
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.
Matched on
terms: error, medical
PFD report
61match
Freddie Dobinson-Evans
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.
Matched on
terms: error
PFD report
61match
Jade Revell
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.
Matched on
terms: display
PFD report
61match
June Liddell
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.
Matched on
terms: error
Committee recommendation
60match
#8 - 11th Report – Cosmetic procedures
The Government should increase the information available on the approval of medical devices to allow interested parties to see not only what devices are approved but the evidence base underpinning the decisions to approve them. (Recommendation, Paragraph 36)
Matched on
terms: device, medical
PFD report
57match
Archie Hames
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.
Matched on
terms: device
PFD report
57match
Donald Till
Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.
Matched on
terms: medical
PFD report
57match
Norman Pirie
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.
Matched on
terms: device
PFD report
57match
Andrew Cook
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.
Matched on
terms: medical
PFD report
57match
Ben Harrison
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.
Matched on
terms: medical
PFD report
57match
Michael Walton
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.
Matched on
terms: medical
Article 2 learning point
56match
Mr Quartz — HMP Doncaster - LP 9
We recommend that Doncaster Prison develops a robust system for testing and ensuring that all medical devices, including defibrillators, are in full working order.
Matched on
terms: device, medical
Committee recommendation
55match
#17 - Forty-Seventh Report - COVID-19: Test, track and trace (part 1)
We are aware that the Medicines and Healthcare products Regulatory Agency (MHRA), the government’s regulatory body which approves medical devices, approved 51 https://www.gov.uk/government/news/staggered-rollout-of-coronavirus-testing-for-secondary-schools- and-colleges; https://www.gov.uk/government/publications/coronavirus-covid-19-asymptomatic-testing-in- schools-and-colleges/coronavirus-covid-19-asymptomatic-testing-in-schools-and-colleges; https://www.gov.uk/ government/news/all-students-offered-testing-on-return-to-university 52 Qq 13, 16–17, 118 53 C&AG’s Report paras 1.28–1.29 54 Q 117 55 For example:https://www.bma.org.uk/news-and-opinion/the-implications-of-rapid-testing-for-nhs-workers; https://www.bmj.com/content/371/bmj.m4436 56 See, for example, https://www.bmj.com/content/371/bmj.m4916 57 Q 116; https://www.gov.uk/government/publications/evidence-on-the-accuracy-of-lateral-flow-device-testing/ evidence-summary-for-lateral-flow-devices-lfd-in-relation-to-care-homes 58 https://www.liverpool.ac.uk/research/news/articles/covid-19-liverpool-community-testing-pilot-interim-findings- published/...
Matched on
terms: device, medical
CQC action
51match
Natasha Lucy Clinics
Continue to seek assurances that emergency medical equipment is properly maintained, in line with medical devices regulations.
Matched on
terms: device, medical
PFD report
49match
Jackson Mitchell
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.
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classifier match
PFD report
49match
Gaenor Moore
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.
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PFD report
49match
Geoffrey Parry
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.
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PFD report
49match
Glenys Pollitt
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.
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PFD report
49match
Ivan O’Neill
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.
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PFD report
49match
Chimezie Daniels
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.
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PFD report
49match
Sangeerth Girirathan
Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in a cardiac arrest.
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PFD report
49match
Devon Turner
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.
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PFD report
49match
Jake Lawler
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.
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PFD report
49match
Melanie Walker
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.
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PHSO casework decision
48match
P-003019 - South Tyneside and Sunderland NHS Foundation Trust
Mrs N complains the Trust’s emergency department did not take appropriate action when she presented with problems with a recently fitted cardiac device.
Matched on
terms: device
PFD report
45match
Kenneth Smalley
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.
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classifier match
PFD report
45match
Arthur Brockett-Deakins
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.
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PFD report
45match
Marjorie Phillips
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.
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PFD report
45match
James Fyfe
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.
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PFD report
45match
Brian Marks
PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.
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PFD report
45match
Steven Curtis
There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin of the accident ladder.
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PFD report
45match
Dilys Jenkins
Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
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PFD report
45match
James Hedge
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
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PFD report
45match
Joseph De Pellergrino-Farrugia
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.
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PFD report
45match
Peter Cotter
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.
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PFD report
45match
Jeanette Robinson
The coroner raises concerns about the lack of an alarm on a Nimbus 3 air mattress, which deflated when its power cable was dislodged, contributing to the patient's death.
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PFD report
45match
Doris Clark
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.
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PFD report
45match
Leslie Harris
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.
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PFD report
45match
Stephen Oakes
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.
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PFD report
45match
Peter Hussey
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.
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PFD report
45match
Don Fernandes
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.
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PFD report
45match
Kishorkumar Patel and Kofi Aning
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.
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classifier match
PFD report
45match
Ann Geraghty
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.
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PFD report
45match
Diana Reay
Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.
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classifier match
PFD report
45match
Mary Land
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.
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PFD report
45match
Van Tuyen
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
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PFD report
45match
Lauren Smith
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.
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PFD report
45match
Thomas Wakefield
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.
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PFD report
45match
Kathleen Gregory
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
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