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National Patient Safety Agency

Clinicians urged to check levels of intravenous fluids for neonates

2 September 2010

The National Patient Safety Agency (NPSA) has issued a Rapid Response Report (RRR) alerting NHS organisations in England and Wales to the risk of the accidental over infusion of intravenous fluids and medicines to neonates*.


The RRR, Prevention of over infusion of intravenous fluid and medicines in neonates, highlights the dangers of accidental over infusion of intravenous fluids and medicines to neonates. This can occur during the setting up of specific intravenous infusions or as a result of the overriding of safety mechanisms on infusion pumps and has the potential to result in death.


The actions to help prevent over infusion contained within the report have been produced by the NPSA with support from neonatal clinicians and the NHS community. It asks clinicians to ensure that a local neonatal intravenous administration policy is available and that it specifies:


• when using a syringe pump to administer intravenous fluids or medicines to neonates, a bag of fluid should not be left connected to the syringe;

• all clamps on intravenous administration sets must be closed before removing the administration set from the infusion pump, or switching the pump off. This is required regardless of whether the administration set has an anti-free flow device;

• the frequency and responsibility for monitoring:
i. the intravenous infusion device
ii. the infusion administration equipment 
iii. the patient receiving intravenous infusion


In addition, NHS organisations are also encouraged to include the above actions in their education, training and assessment programmes.


The NPSA’s Patient Safety Lead for Child Health, Jenny Mooney, said: “The administration of intravenous fluids and medicines to neonates is often an integral part of their care. The weight and size of the baby and the often critical nature of their medical condition are additional risk factors within this process. These latest guidelines provide clinicians with specific actions that will help reduce the risk of accidental over infusion of intravenous fluid and medicine to this vulnerable group of patients.”


NHS organisations are required to complete these actions by 28 February 2011.




Notes to editors

1. Media enquiries to the NPSA Press Office:


Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk


Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.


3. * This action does not apply to the administration of blood components to neonates. These should continue to be administered as per The British Committee for Standards in Haematology ‘Guidelines on the Administration of Blood Components’ (2009) www.bcshguidelines.org/pdf/Admin_blood_components050110.pdf
(Page 51)


4. The RRR is available from the NPSA website: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=75519