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Never events

Air embolus

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The last of a four-part series on some of the main changes to the Department of Health’s new extended never events list discusses preventing air embolus

Huehns T (2011) Air embolus. Nursing Times; 107: early online publication

Keywords: Never Events, Air embolus, Patient safety, Vascular devices

  • This article has been double-blind peer reviewed

In this article…

  • Consequences of failing to avoid air embolus when inserting, removing and accessing vascular access devices
  • Recognising and preventing a nearly never event

 

5 key points

  • A protocol for the insertion, removal and use of vascular access devices (VADs) should be available
  • VADs must be removed only by a someone with training, skills, knowledge and experience in this
  • Caution should be used when removing central venous catheters. This includes lying the patient flat with head down, digital pressure and airtight dressings
  • Practitioners should be aware of air embolus associated with VADs and its prevention
  • Practitioners should know how to recognise and act on an air embolism

Air embolism causing harm to patients can occur in association with vascular access devices, such as central venous catheters and haemodialysis circuits. Practitioners must avoid introducing an air embolus when inserting, removing and accessing such devices.

Case study

Sarah runs the renal unit in a general hospital. David Parker had a renal transplant five days ago and has been making progress with good renal function. He is expected to be transferred to a more general ward, but first needs his central line removed. Sarah bleeps the junior doctor to remove it.

As the doctor arrives, Sarah is receiving a new admission from theatre. The doctor comes to find Sarah, who waves her through as the doctor is familiar with Mr Parker. He and the doctor are similar ages and have known each other for months from the dialysis unit and now through the successful transplant. Mr Parker is sitting up and reading, and they chat as the doctor sets up a trolley.

Sarah can see out of the corner of her eye the doctor leaning forward and carefully pulling the central line out. There is a cry from the bed, and Mr Parker’s eyes close and he is breathing heavily. The doctor covers the hole with a swab and asks “Are you OK?” Sarah rushes in.

Mr Parker is breathing and his pulse is regular. He says: “I have a funny feeling in my leg, doctor.” Sarah and the doctor lay him flat and check his observations again. He seems to be able to move his legs properly. Suddenly, the doctor realises that Mr Parker should have been lying down for central line removal and that air might have gone into the vein when she removed the line. She thinks he might have had a transient ischaemic attack as a result.

Recognising a possible never event

Sarah has worked in theatres and knows a lot about the surgical checklist. When wrong site surgery became a never event this raised its profile even more.

Sarah has taught her staff about the new never events, particularly those relating to renal work. These mainly concern: medication (wrongly prepared high-risk drugs, maladministration of potassium-containing solutions, intravenous administration of epidural medication and maladministration of insulin); blood and organ transplant incompatibility; oxygen saturation monitoring; and air embolism.

She immediately realises this is potentially serious and, after making sure Mr Parker is unharmed, she talks to the doctor. The doctor also recognises the issue from reading around never events, and is shocked she has made such a serious error. She agrees this could have resulted in serious harm and would have been a never event.

Sarah talks it through and suggests the doctor gets support from her clinical director, as well as apologises to the patient.

This incident should be reported to the commissioner and to the local risk management system (Department of Health, 2011).

Prevention

The doctor suggests raising the issue with her clinical director and at the next doctors’ clinical meeting to share good practice. Sarah prints out slides from the recent nurse training on never events in the renal unit that she attended, and the doctor will show these to her medical colleagues.

In this case, there was no death or severe harm, but there are lessons to be learnt from this nearly never event and reporting and investigation should be taken seriously. NT

Dr Tanya Huehns is former head of patient safety strategy at the National Patient Safety Agency

Box 1. Never event: air embolism

  • Death or severe harm as a result of intravascular air embolism introduced during intravascular infusion/bolus administration or through a haemodialysis circuit
  • Excludes the introduction of air emboli through other routes, such as via surgical intervention (particularly ear, nose and throat surgery and neurosurgery), during foam scleropathy and during the insertion of a central venous catheter
  • Includes the introduction of an air embolus after the insertion of a central venous catheter, through the line and during its removal
  • Excludes where an air embolism was introduced because of a patient’s action
  • Settings: all healthcare premises

Source: Department of Health (2011)

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