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13-08-2008 Back to news index
Problems with infusions and sampling from arterial lines
Rapid Response Report from NPSA
The National Patient Safety Agency (NPSA) has issued a Rapid Response Report to healthcare professionals in the UK to offer guidance for arterial line use following reports of problems with infusions and sampling.
From January 2005 to June 2008, the NPSA had reports of two deaths and 82 other incidents where the wrong infusion fluid was attached to the arterial line. A further 76 incidents, including one case of serious harm, related to faulty sampling technique. All of these incidents were reported to the National Reporting and Learning System (NRLS).
Arterial lines are routinely used in critical care areas to obtain samples of arterial blood, to test for blood gases, glucose and electrolytes. Slow infusions of sodium chloride or heparinised saline are currently used to keep the arterial line open. Patients may be harmed if the wrong infusion is given to keep the line open or when poor sampling leads to delayed or inappropriate treatment.
This Rapid Response Report calls for immediate action by medical and nursing directors in the NHS and the independent sector to ensure the following:
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Sampling from arterial lines is risky and should only be done by competent, trained staff.
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Arterial infusion lines must be clearly identified.
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Any infusion (or additive) attached to an arterial line must be prescribed and checked before administration.
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Staff should use only sodium chloride 0.9% to keep lines open.
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Labels should clearly identify contents of infusion bags, even when pressure bags are used.
The NPSA is calling for the implementation of these recommendations by 30 January 2009.