Patient hoists and slings - ensure you follow manufacturer's instructions for use and that you carry out risk assessments

(All) MHRA continues to receive adverse incident reports of patient hoists and slings used in hospitals and the community that have resulted in serious patient injury or fatalities. (MDA/2007/031)

23 April 2007 at 14:30

Ref: MDA/2007/031

Action deadlines for the Safety Alert Broadcast System (SABS)

Deadline (action underway): 29 June 2007, Deadline (action complete): 31 August 2007

Device

Patient hoists and slings.

Problem

Falls due to the poor compatibility of slings and hoists, inappropriate laundering of slings and inadequate maintenance of patient hoists used in hospitals and the community.

Hoists and slings are used to transfer patients and this is usually achieved very successfully.

However, the MHRA continues to receive adverse incident reports involving patient hoists and slings used in hospitals and the community. Some of these incidents have resulted in serious patient injury or fatalities.

Some examples of these incidents are:

  • Whilst being hoisted a patient fell to the floor through an aperture in the patient sling. This aperture resulted from an incompatibility of the sling and the spreader bar. Also, the sling was an inappropriate size for the patient’s weight and body size
  • Carers have received electric shocks from contact with damaged leads and connectors when recharging hoist batteries. This damage should have been detected on visual inspection before use or during maintenance
  • Slings being laundered/washed by methods not in accordance with the manufacturer’s instructions have produced weaknesses in the slings and their mounting systems, leading to subsequent failure in use
  • Single-use slings were laundered with reusable slings. Single-use slings are not manufactured to be laundered and reused. Patients being lifted in these slings could be put at increased risk
  • A LOLER inspection revealed a hoist electric actuator had exceeded its manufacturer’s cyclic design life. The hoist was kept in service following the inspection without the actuator being changed, which subsequently failed in use.

This Alert replaces earlier notices SN9829 (July 1998) and SN1999 (29) (September 1999), which are now withdrawn.

Action

Ensure that:

  • All hoists and slings are used and maintained in accordance with the manufacturer’s instructions
  • All sling and hoist combinations are compatible and appropriate for the patient and that risk assessments are repeated if the equipment combination or the patient’s condition changes
  • All hoists and slings are visually inspected before use and are removed from service if defects are found
  • All slings are cleaned in accordance with the manufacturer’s instructions
  • All hoists and slings are inspected by a competent person every six months as outlined in the Lifting Operations and Lifting Equipment Regulations (LOLER)

Action by

All those involved in the supply, maintenance or use of these devices, in particular nurses, care staff, laundry staff and maintenance staff or contractors.

Distribution

Please bring this notice to the attention of all who need to know or be aware of it. This may include distribution by:

Trusts to:

SABS liaison officers for onward distribution to all relevant staff including:

  • Clinical governance leads
  • Equipment stores
  • Estates and facilities managers
  • Health and safety managers
  • Laundry managers or contractors
  • Maintenance staff and contractors
  • Manual handling trainers
  • Modern matrons
  • Nursing staff
  • Occupational therapists
  • Physiotherapists
  • Purchasing managers
  • Risk managers
  • Safety officers

Healthcare Commission (CHAI) to:Headquarters for onward distribution to:

  • Clinics
  • Hospices
  • Hospitals in the independent sector

Commission for Social Care Inspection (CSCI) to:

Headquarters for onward distribution to:

  • Care homes (adults, older people and children)
  • Domiciliary care providers
  • Laundry managers or contractors
  • Nursing agencies
  • Residential special schools
  • Staff undertaking care home inspection

Primary care trusts to:

SABS liaison officers for onward distribution to all relevant staff including:

  • Community hospitals
  • District nurses
  • Estate and facilities managers
  • Health and safety managers
  • Laundry managers or contractors
  • Maintenance staff and contractors
  • Manual handling trainers
  • Nursing executive directors
  • Occupational therapists
  • Physiotherapists

Social services to:

Liaison officers for onward distribution to all relevant staff including:

  • Back care/manual handling advisors
  • Care at home staff
  • Care management team managers
  • Day centres (older people, learning disabilities, mental health, physical disabilities, respite care, autistic services)
  • Disability equipment stores
  • Education departments for equipment held in schools
  • Equipment stores
  • Laundry managers or contractors
  • Loan store managers
  • Maintenance services or contractors
  • Occupational therapists
  • Residential care homes

Contacts

Enquiries to the MHRA should quote reference number 2006/011/013/291/004 and be addressed to:

Technical aspects

John Ward or Sharon Knight
Medicines & Healthcare products Regulatory Agency
Market Towers
1 Nine Elms Lane
London SW8 5NQ

Tel: 020 7084 3232 / 3202
Fax: 020 7084 3209

E-mail: john.ward@mhra.gsi.gov.uk & sharon.knight@mhra.gsi.gov.uk

Clinical aspects

Jonathan Plumb
Medicines & Healthcare products Regulatory Agency
Market Towers
1 Nine Elms Lane
London SW8 5NQ

Tel: 020 7084 3218
Fax: 020 7084 3111

E-mail: jonathan.plumb@mhra.gsi.gov.uk

Change of address or removal from address list for Healthcare Commission:

CSCI Customer Service Unit
St Nicholas Building
St Nicholas Street
Newcastle-upon-Tyne
NE1 1NB

Tel: 0845 015 0120
E-mail: enquiries@csci.gsi.gov.uk

Healthcare Commission
Finsbury Tower
103-105 Bunhill Row
London
EC1Y 8TG

Tel: 020 7448 0842

E-mail: contacts@healthcarecommission.org.uk

How to report adverse incidents

Incidents relating to medical devices must be reported to the Medicines and Healthcare products Regulatory Agency (MHRA) as soon as possible.

Further information about reporting incidents; online incident reporting facilities; and downloadable report forms are available from MHRA’s website (http://www.mhra.gov.uk).

Alternatively, further information and printed incident report forms are available from:

MHRA Adverse Incident Centre
Medicines and Healthcare products Regulatory Agency
Market Towers, 1 Nine Elms Lane
London SW8 5NQ

Telephone 020 7084 3080 or Fax 020 7084 3109 or e-mail: aic@mhra.gsi.gov.uk(An answerphone service operates outside normal officer hours)

Medical Device Alerts are available in full text on the MHRA website:http://www.mhra.gov.uk

Further information about SABS can be found at www.info.doh.gov.uk/sar2/cmopatie.nsf

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