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National Patient Safety Agency

New guidance issued following problems with infusions and sampling from arterial lines

30 July 2008


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:


  • Sampling from arterial lines is risky and should only be done by competent, trained staff.


  • Arterial infusion lines must be clearly identified.


  • Any infusion (or additive) attached to an arterial line must be prescribed and checked before administration.


  • Staff should use only sodium chloride 0.9% to keep lines open.


  • Labels should clearly identify contents of infusion bags, even when pressure bags are used.


Linda Matthew, Senior Pharmacist at the NPSA, said:  “Arterial lines are routinely used in critical care areas and it is crucial that they are used safely and correctly in all instances.  It is vital that staff are appropriately trained before using arterial lines and we want to see pharmaceutical manufacturers following our labelling design guidance to prevent confusion over medication type.”


The NPSA is calling for the implementation of these recommendations by 30 January 2009.


View the Rapid Response Report.




Notes for editors:


Media enquiries to Amelia Lyons in the NPSA Communications Department on 0207 927 9580, amelia.lyons@npsa.nhs.uk or Paul Cooney on 0207 927 9351, paul.cooney@npsa.nhs.uk


The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes. For more information about the Agency and its activities please visit our website www.npsa.nhs.uk.


National Reporting and Learning System (NRLS)

The NPSA collects and analyses reports of patient safety incidents received from NHS staff through its National Reporting and Learning System (NRLS).  This data includes all patient safety incidents reported from NHS organisations in England and Wales.  The findings are then reported back to the NHS and the public via regular alerts (such as the Rapid Response Report), quarterly data summary and bulletins, with the aim of improving patient safety. 


All NHS organisations have been connected to the NRLS since January 2005 and more than 2 million incidents have been received to date.  We also receive reports via our service eform from NHS Direct and community pharmacies.


It is important to note that volume of reports received by the NRLS has steadily increased since inception and as the NRLS is a voluntary reporting system, the data may not be representative of the rates of incidents across England and Wales.


Rapid Response Reports

Since June 2007, the NPSA has been issuing one-page notices with supporting information to NHS organisations about risks to patients. These are called Rapid Response Reports and eight have been issued to date.  These are issued to all NHS organisations, in England and Wales, presenting the evidence of harm to patients and identifying clear actions to reduce risks.


Safer Design

Safer Design is a vital part of improving patient safety.  The National Patient Safety Agency is involved in a series of initiatives to facilitate safer design in several areas of health care. This includes a guide to labelling and packaging of injectable medicines.