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Operating theatre safety warning

Six serious incidents due to residual anaesthetic drugs in cannulae or IV lines

Mark Gould

Wednesday, 16 April 2014

NHS England has issued a patient safety alert amid concerns that poor flushing techniques mean residual amounts of anaesthetic drugs remain in cannulae and intravenous lines which could lead to cardiac or respiratory arrest.

Since January 2011 there have been six incidents of cardiac or respiratory arrest due to residual anaesthetic drugs in cannulae reported to the National Reporting and Learning System (NRLS).

NHS England says that during intravenous anaesthesia, some drug may be left in the cannula, or in the intravenous line distal to a site of drug injection, which is then flushed into the patient’s circulation when further fluid or medication is given through the same cannula or line. This may also happen when ward staff give antibiotics or pain relief after the patient returns from theatre.

From the incidents reported it appears that systems were not in place to ensure that all cannulae and extensions were flushed with saline or another solution that does not contain anaesthetic drugs before the patient left recovery or the department where the procedure or investigation was undertaken.

The alert has been issued to all NHS services hospitals and community services in England that undertake surgery or other investigations and procedures using anaesthesia.

Dr Mike Durkin, National Director of Patient Safety, NHS England, said: “This is now the eighth alert we have issued using NHS England’s National Patient Safety Alerting System, which was launched in January. Patient safety alerts can cover all aspects of healthcare and are a crucial part of our work to rapidly alert NHS providers to risks and provide guidance on preventing potential incidents that may lead to harm or death. Incidents are identified using our reporting system to spot emerging patterns at a national level, so that appropriate guidance can be developed and issued to protect patients from harm.”

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