This Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines.
Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left.
Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death.
The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic.
It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure.
The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
HSIB makes the following safety recommendations
- HSIB recommends that the Royal College of Anaesthetists and Centre for Perioperative Care work with relevant stakeholders, such as the Association of Anaesthetists, College of Operating Department Practitioners, and Association for Perioperative Practice, to review, update and integrate new guidance on the surgical safety checklist ‘SignOut’ process. Specifically, the guidance should be updated in relation to the flushing of cannulae and extension lines by strengthening the current administrative barriers, considering the hierarchy of hazard control, and the issues identified by the HSIB investigation.
- HSIB recommends that the Royal College of Anaesthetists reviews its ‘Guidelines for the provision of anaesthetic services’ regarding the planning and oversight of perianaesthetic care in non-theatre settings. This should include: 1 guidance to assist anaesthetic departments to consistently plan for short-notice or emergency cases which take place in the nontheatre setting; 2 planning which considers and mitigates against unexpected changes in conditions.
HSIB makes the following safety observations
- It may be beneficial for healthcare trusts to adopt the programme provided by Health Education England for intravenous (IV) skills, which supports the competency requirements published by the Nursing and Midwifery Council.
- It may be beneficial to increase the use of body maps to record the presence of all indwelling items, such as cannulae, catheter and drains, during an anaesthetic procedure. The body map could be used as part of an enhanced sign-out and to provide instructions for the management of each indwelling item in the postoperative period.
- It may be beneficial for manufacturers to further standardise product specifications to design out the potential for errors. For example, items such as Y-connectors, extension lines and needle-free connectors often look similar but may have differing specifications.