title: Management of arterial lines and blood sampling in intensive care: a threat to patient safety.
abstract: In 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in our intensive care unit (ICU), we surveyed current practice in arterial line management and determined whether these recommendations had been adopted. We contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented - use of sodium chloride 0.9% as flush fluid, two-person checking of fluids before use - and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two-person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. Our survey provides evidence of continuing risk to patients.
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK.
authors.forename: R A
authors.initials: RA
authors.lastname: Leslie
authors.forename: S
authors.initials: S
authors.lastname: Gouldson
authors.forename: N
authors.initials: N
authors.lastname: Habib
authors.forename: N
authors.initials: N
authors.lastname: Harris
authors.forename: H
authors.initials: H
authors.lastname: Murray
authors.forename: V
authors.initials: V
authors.lastname: Wells
authors.forename: T M
authors.initials: TM
authors.lastname: Cook
mesh_terms: D000328:Adult; D001800:Blood Specimen Collection / Q000379:methods* / Q000592:standards* / Q000706:statistics & numerical data; D003422:Critical Care / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data; D019538:Health Care Surveys / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000706:statistics & numerical data; D019300:Medical Errors / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D006113:United Kingdom; D062666:Vascular Access Devices / Q000592:standards* / Q000706:statistics & numerical data