Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis

Abstract

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.

A reply

“…We are grateful for Dr Fawcett's comments on our article [1]. We can confirm that when blood gas and laboratory samples were being sampled from the arterial line flushed with sodium chloride 0.9% with glucose 5%, no dramatic changes of sodium, potassium or chloride occurred and these stayed within the laboratory reference ranges.…”

“…Drs Gupta and Cook are to be congratulated on their honest, open and expertly analysed case [1]. I was also interested to read the accompanying article by Smith [2] and the related article by Leslie et al [3].…”

“…Other blood biochemistry is highly unlikely to be dramatically altered. Hypoglycaemia associated with the use of incorrect arterial flush solutions I read the report of accidental hypoglycaemia reported in Anaesthesia with a sense of inevitability [1]. The problems that led to the publication of the NPSA guidance on arterial lines [2] had clearly not gone away after the guidance had been published and were identified in a review of patient safety incidents during 2009 and 2010 [3].…”

“…In the excellent editorial [7] commenting on the case report [1], Prof. Smith points out that we need systems in place to identify lessons that we may otherwise forget. I would strongly suggest that all critical care networks review their patient safety incidents using processes that we have developed and …”

The effect of hyperglycaemia on haemostasis testing – a volunteer study

“…Among the various types of potential errors that may occur during blood collection from vascular devices, blood sample contamination with glucose solutions has been described as an important cause of spurious hyperglycaemia [2,3], which may occasionally lead to serious harm due to unwarranted prescription of insulin and consequent iatrogenic hypoglycaemia [4,5].…”