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Safety alert issued on removal or flushing of lines and cannulae after procedures

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A safety alert has been issued on the need for hospital staff to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of procedures.

The alert was issued by the regulator NHS Improvement on Thursday and is targeted at NHS providers that undertake surgical interventions or other procedures involving anaesthesia or IV sedation.

“This directive alert now requires all organisations to embed these changes”

Safety alert

It said patient safety incidents were occurring from lapses in identifying and flushing all IV lines and cannulae at the end of a procedure when anaesthetic or intravenous sedative drugs had been given.

It noted that residual anaesthetic and sedative drugs could later be inadvertently introduced into the patient’s circulation causing muscle paralysis, unconsciousness and respiratory and cardiac arrest.

As a result, providers have been told to amend safe surgery checklists to include confirmation that, before a patient leaves the procedural area, cannulae and IV lines have been removed or flushed.

They must also include in handover notes – from procedural area to recovery, and recovery to the subsequent place of care – the requirement for documented and verbal confirmation that lines not in active use have been removed and multi-lumen connectors and cannulae removed or flushed.

In addition, they should “establish ongoing systems of audit to ensure these barriers are maintained”, stated the alert.

The alert highlighted that risk had been known for some time and a previous warning has been issued in April 2014.

“The residual drug can be later inadvertently introduced into the patient’s circulation”

Safety alert

However, it noted that in the three years since then, 58 similar incidents involving either anaesthetic or sedative drugs in adults or children have been reported.

Of these, 18 were reported as causing respiratory arrest and the remaining incidents described effects including temporary paralysis, muscle spasms, and difficulty breathing.

“Whilst incidents are still occurring from lapses in identifying and flushing all IV lines and cannulae intended for further use; they are also resulting from failure at the end of a procedure to remove cannulae specifically inserted to administer anaesthetic and sedative drugs,” it said.

“Another important risk is when two or more IV lines or ports are connected to the same cannula, as flushes may not remove drugs that have back-tracked up one of the lines or accumulated in the additional space within multi-lumen connectors,” said the alert.

It noted that the use of infusion sets and ports with one-way valves reduced the risk of backtracking.

NHS Improvement also highlighted that, since 2014, a range of local procedures had been identified to ensure patients did not return to wards with cannulae or lines in place that contained residual drugs.

“The most effective of these centre on adding prompts to existing procedure documentation and at patient handover from clinicians in the procedural area, confirming that all cannulae and IV lines that may contain residual drugs have been fully flushed or removed,” it said.

It added: “This directive alert now requires all organisations to embed these changes.”

Trusts have been told to start implementing the changes “as soon as possible” and be completed by 9 August 2018.

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