Accidental hypoglycaemia caused by an arterial flush drug error

We read with great interest the recent articles about iatrogenic neuroglycopenia [1–3] and the Association of Anaesthetists of Great Britain & Ireland’s guidelines [4]. The authors should be complimented for their exceptional effort in further raising the profile and magnitude of this ongoing problem, which continues to put patient at risk despite the National Patient Safety Agency alert of 2008 [5]. We also viewed the articles with self-reproach, as we had encountered a similar incident in our Trust in 2012. We have implemented a series of changes following this and other incidents, including mandating the use of 500-ml bags of saline 0.9%, a signed, designated prescription sticker and double-checking before connection. Although seemingly robust, this response was still not enough. As with the author’s report, we also found ongoing problems caused by the pressure infusor cuffs in use: despite being ‘transparent’, they obstruct a clear view of the labelling on the fluid bags. In developing a response to this issue we came across three different, commonly available types of pressure infuser cuffs (Fig. 7): 1. Net-sided: these have an opaque pressure cuff with a side-pouch made of netting. Examples are the Infu-Surg (Ethox International, Buffalo, NY, USA) and Accu-PRO (Proact Medical, Corby, Northants, UK). 2. Completely clear: these have a cuff that is virtually or completely clear. Only two such products exist: the Clear-Cuff and C-Fusor (Smiths Medical, St. Paul, MN, USA). 3. Clear-sided: these have an opaque pressure cuff with a sidepouch made of clear material. Examples are the InfuseIT (Zefon international, Ocala, Florida, USA) and Unifusor (Armstrong Medical, Coleraine, Northern Ireland).