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Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis
Author(s) -
Gupta K. J.,
Cook T. M.
Publication year - 2013
Publication title -
anaesthesia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.839
H-Index - 117
eISSN - 1365-2044
pISSN - 0003-2409
DOI - 10.1111/anae.12388
Subject(s) - medicine , accidental , arterial line , patient safety , arterial blood gas analysis , emergency medicine , intensive care medicine , anesthesia , surgery , medical emergency , health care , physics , acoustics , economics , economic growth
Summary In 2008, the National Patient Safety Agency ( NPSA ) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. We report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. We report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. We discuss the nature of the errors that occurred and list the consequent changes in practice implemented on our unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.