Through its core work to review patients safety events recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified issues around distinguishing between haemofilters and plasma filters to reduce mis-selection.
Following review of a manufacturer’s Field Safety Notice (FSN) we identified that haemofilters and plasma filters look similar, require the same connections, and are frequently used in similar clinical locations; whilst serving different functions.
Haemofilters and plasma filters are both used when it is necessary to separate out toxins from a patient’s blood system however inadvertent use of a plasma filter instead of a haemofilter during renal replacement therapy could lead to significant hemodynamic compromise which could be fatal in the acutely ill patient.
We were concerned that the similarity in design presented an increased risk of selection error, and reports to manufacturers corroborated that plasma filters have been inadvertently used instead of a haemofilter.
We worked with the Medicines and Healthcare products Regulatory Authority to issue a Medical Device Alert (MDA), alerting healthcare professionals to the risk of serious injury or death if the manufacturer’s instructions on set-up are not followed.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.