From January 2005 to January 2008, the agency had reports of two deaths and 82 incidents where the wrong infusion fluid was attached to the arterial line.
A further 76 incidents, including one of serious harm related to faulty sampling technique and all of these incidents were reported to the National Reporting and Learning System (NRLS).
The Rapid Response Report calls for immediate action by medical and nursing directors in the NHS and the independent sector to ensure only competent, trained staff sample from arterial lines.
Arterial infusion lines must be clearly identified and that any infusion is checked before administration.
Staff should use only sodium chloride 0.9% to keep lines open and labels should clearly identify contents of infusion bags, even when pressure bags are used.
Recommendations should be implemented by 30 January 2009.