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Infusions and sampling from arterial lines Rapid Response Report

Infusions and sampling from arterial lines Rapid Response Report
Reference number
1069
Central Alert System (CAS) reference
NPSA/2008/RRR006
Issue date28 July 2008
Action date (if applicable) (date field)30 January 2009
DH Gateway reference
10312
TypeAlert

This document recommends the use of sodium chloride 0.9% to keep arterial lines open.


Arterial lines are routinely used in critical care areas for sampling arterial blood to measure blood gases, glucose and electrolytes. 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.


High risk situations reported include sampling blood glucose from lines with glucose running and mis-selecting potassium chloride for injection.


Contributing factors include lookalike labelling and packaging of intravenous infusion bags and inadequate checking before attachment. A particular risk is the need to cover the infusion with a pressure bag which obscures the label during use. Risks of confusion are increased when patients are transferred from other areas.


Sampling errors include problems when taking and managing the samples, contamination by inadequate flushing and confusing arterial with venous lines.


The guidance applies mainly to critical care, and other areas such as emergency departments where arterial lines are put up and managed. NHS organisations can still comply with this guidance if they use heparinised saline or another suitable infusion not containing glucose.


This document is accompanied by supporting information which includes a review of evidence of harm and a literature search.

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Arterial lines - Rapid Response Report
Arterial lines - Rapid Response Report - 59 KB 1069 - Arterial lines - Rapid Response Report - 2008-07-28 - V1
Arterial lines - Rapid Response Report supporting information
Arterial lines - Rapid Response Report supporting information - 128 KB 1069A - Arterial lines - Rapid Response Report supporting information - 2008-07-28 - V1