Lest we forget: learning and remembering in clinical practice

Accidental hypoglycaemia caused by an arterial flush drug error

“…We read with great interest the recent articles about iatrogenic neuroglycopenia [1][2][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].…”

“…Drug costs associated with anaesthesia can be reduced by supplying information about drug costs [1]. However, price lists may not be effective when they are long, show unit prices instead of cost-per-hour, or involve essential drugs with no low-cost alternative [2].…”

A reply

“…I was also interested to read the accompanying article by Smith [2] and the related article by Leslie et al [3].…”

“…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]. Following that review, I had written to highlight the problem to senior colleagues in critical care and, in an unpublished review, described the factors that should be addressed to prevent ongoing episodes of hypoglycaemia associated with the use of incorrect arterial flush solutions [4].…”

“…The guidance on arterial lines issued by the NPSA clearly states that saline should be used in the constitution of arterial lines [2], but this guidance was given on the misconception by staff at the NPSA that clinical staff deliberately selected non-saline solutions. The guidance was not intended to say that specifically heparin should be avoided, and further guidance on heparin specifically excluded arterial lines [5].…”