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  • HSIB: Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment (30 March 2023)


    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • HSIB
    • 30/03/23
    • Health and care staff, Patient safety leads

    Summary

    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line.

    The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream).

    This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.

    Content

    Findings

    • The investigation found there are currently no long-term haemodialysis catheters on the UK market, or being developed, that have integrated ‘safety-valves’.
    • Manual clamps on haemodialysis catheters rely on people ensuring that the clamp is on before accessing the haemodialysis catheter ports and do not mitigate against design-induced error.
    • A review of patient safety risks associated with other haemodialysis devices (for example, fistulas) showed several mitigations which are not consistently used for haemodialysis catheters. These include a coloured patient wristband, line labelling, alert cards being carried by the patient and educating patients/family members.
    • The training and education of all grades of medical staff has not been consistent in relation to the risks of catheter-related air embolism.
    • There is currently no recognised national training or national training guidelines regarding the safe access of haemodialysis catheters.
    • Incidents appear to be under-reported to the Medicines and Healthcare products Regulatory Agency, due to misconceptions about ‘human error’ being the cause, rather than the design of the equipment.
    • The Medicines and Healthcare products Regulatory Agency, in partnership with NHS England, have explored integrated incident reporting system possibilities. While a recent funding bid to support full development for an in-service solution was unsuccessful, the organisations are committed to drive this project forward.
    • There is a general lack of literature on, and knowledge of, catheter-related air embolism in relation to access when the catheter is in situ (in position), rather than during insertion or removal of the catheter.

    Safety recommendations

    • HSIB recommends that the General Medical Council engages with relevant stakeholders to amend the procedure for taking blood cultures in its ‘Practical skills and procedures’ guidance, making clear that the procedure relates to taking blood from a peripheral site, so mitigating the risks to patient safety associated with central lines.
    • HSIB recommends that the General Medical Council, supported by the Medical Schools Council, revises ‘Achieving good medical practice’ to include guidance for medical students on how to handle uncertainty in clinical settings, including challenging a culture, or an expectation, that a learner undertake unfamiliar tasks to gain competencies without appropriate supervision or support.
    • HSIB recommends that the Medicines and Healthcare products Regulatory Agency amends its 2022 ‘Dialysis guidance’ to include the safety risk of air emboli associated with unclamped haemodialysis catheters.

    Safety observations

    • It may be beneficial for manufacturers of haemodialysis catheters to develop an engineering solution to maintain a sealed system upon disconnection, thereby reducing the risk of an air embolism.
    • It may be beneficial to consider how junior doctors can be supported to work safely within their level of competence and feel empowered to decline tasks they are not competent to undertake, with specific reference to the safety risks associated with accessing haemodialysis catheters if not trained and competent.
    • It may be beneficial to explore the design of a visual alert which prompts healthcare professionals to the increased safety risks associated with in situ haemodialysis catheters and the access to this medical device by staff specifically trained in their use.
    • It may be beneficial if the approach outlined in the White Paper published by the National Infusion and Vascular Access Society in 2022 was adopted for wider bore lines such as haemodialysis catheters. This is in relation to a standardised structure and approach for the NHS to deliver vascular access services in every hospital.
    HSIB: Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment (30 March 2023) https://hsib-kqcco125-media.s3.amazonaws.com/assets/documents/hsib-report-air-embolus-central-venous-catheters-haemodialysis.pdf
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