Archive July 2008
Trauma treatment award
The US Army have won an invention award for trauma treatment steps that has saved lives and is to be transferred to civilian hospitals. Defense Industry Daily reports… “Damage Control Resuscitation of Severely Injured Soldiers (Army Institute of Surgical Research). This is a new set of treatment steps for the soldiers, who require massive transfusions. Limiting [...]
IPS conference 2008
The inaugural Infection Prevention Society (incorporating the ICNA) Conference & Exhibition will take place from the 22nd-24th September 2008 at the Harrogate International Centre. This key Infection Prevention and Control Conference is an essential event for anyone who has the challenge of preventing and controlling infections that occur through the provision of care or in the [...]
Addenbrooke’s IV conference
Addenbrooke’s Hospital, UK are holding an International IV Conference ‘Vascular Access – Enhancing Best Practice’ This international conference is aimed at all multi-disciplinary teams who are involved in intravenous therapy and central venous access. The conference runs for two days starting on the 25th September 2008. Key themes include: insertion, care and complications of intravenous devices, [...]
Wristbands reduce errors
Three companies have been contracted to supply wristbands to NHS hospitals in England and Wales. The contract is designed to address research findings by the National Patient Safety Agency’s (NPSA) that 72% of more than 24,000 annual errors in UK hospitals resulted from instances where patients did not wear wristbands. The wristbands, to be supplied by Laserband [...]
Peripheral IV
Wikipedia is a free online encyclopedia that is reliant upon contribution from its readers. Wikipedia is a source that is often utilized by students learning about new topics. Those learning about intravenous therapy are no different. For this reason here at IVTEAM we feel that the Wikipedia IV pages could benefit from review by the IVTEAM [...]
Incidence of PICC DVT
Loupus et al (2008) conduct a study to determine if there is a statistically significant increase in the incidence PICC related DVT in quadriplegic patients. Loupus, D., Schuetrumpf, S. and Vazquez, L.F. (2008) A Retrospective Review of Peripherally Inserted Central Catheters and Upper Extremity Deep Venous Thrombosis in Persons with Cervical Spinal Cord Injuries. Journal of the Association for Vascular Access. 13(2), p.82-87. Abstract: Introduction: Peripherally [...]
Vascular haemodialysis access
Kawecka et al (2008) analyse the choice and appropriateness of haemodialysis vascular access devices in elderly patients. Kawecka, A., Przekwas, M., Debska-Ślizień, A. and Rutkowski, B. (2008) Elder Patients – What is the Best Vascular Hemodialysis Access? Journal of the Association for Vascular Access. 13(2), p.75-80. Abstract: Background: The incidence of end stage renal disease (ESRD) has increased in recent [...]
IV occlusion and vitamin E
Chernecky et al (2008) published a study in which patients felt that taking vitamin E, 400 -800 IU per day orally, avoided the problems of occlusion or inability to withdraw blood from their current VAD. Chernecky, C., Macklin, D., Nugent, K. and Waller, J. (2008) Potential Value of Vitamin E in Cancer Patients with Venous Access [...]
Medication error prevention
The National Academies (2006) note that medication errors injure 1.5 people annually. This study by Rosenkoetter et al (2008) reports on the impact of “smart pump” technology on medication error prevention. Rosenkoetter, M.M., Bowcutt, M., Khasanshina, E.V., Chernecky, C.C. and Wall, J. (2008) Perceptions of the Impact of “Smart Pumps” on Nurses and Nursing Care Provided. Journal of the [...]
Failure to monitor fluid balance
NHS Tayside has agreed to apologise to the family of a 79-year-old man who died in Ninewells Hospital after knee-replacement surgery. Scottish Public Services Ombudsman Professor Alice Brown said the man — referred to as Mr A — was admitted to Ninewells on April 20, 2006, and had his operation the following day. He later suffered [...]
Urokinase meta-analysis
The authors completed a meta-analysis of prospective randomized trials that examine the use of Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy. Kethireddy, S. and Safdar, N. (2008) Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy: a meta-analysis of prospective [...]
Heparin update New Zealand
Stewart Jessamine, Group Manager, Medsafe in conjunction with the Ministry of Health (NZ) are continuing to monitor the situation with respect to the global problem of heparin contaminated with over-sulphated chondroitin sulphate (OSCS) entering the market. Medicines regulators around the world have taken a number of different approaches to managing this issue. In New Zealand, Medsafe [...]
Barcode medication system
Actor Dennis Quaid, whose twins were given an overdose of a blood thinner as newborns at a California hospital, toured a Dallas hospital on Tuesday to learn about a system to prevent such errors. Officials at Children’s Medical Center Dallas showed Quaid and his wife, Kimberly, the hospital’s system of bar-coding medications to allow the drugs [...]
MedPro and Greiner
MedPro Safety Products, has entered into two medical supply manufacturing agreements with Greiner Bio-One International. The two agreements grant Greiner the right to manufacture, market and distribute MedPro’s tube-activated and skin-activated blood collection systems and its winged ‘butterfly’ safety needle system. MedPro’s Chairman and Chief Executive Officer, Craig Turner, stated: “Greiner is a world-class company, [...]
Venepuncture practice
Irene Lavery and Emma Smith from the Western General Hospital, Edinburgh contrast and compare the skill of venepuncture against the 2008 Nursing and Midwifery Council Code. Lavery, I. and Smith, E. (2008) Venepuncture practice and the 2008 nursing and Midwifery Council Code. British Journal of Nursing. 17(13), p.824-828. Abstract: This article explores the new Nursing and Midwifery Council [...]
Safe transfusion
The authors examine issues that impact upon the successful implementation of national guidance such as the NHS better blood transfusion programme and the NPSA safer practice notice 14, right patient, right blood. Gray, A., Hart, M., Dalrymple, K. and Davies, T. (2008) Promoting safe transfusion practice: right blood, right patient, right time. British Journal of [...]
Systematic review anti-infective CVC
These two recently published systematic reviews consider the impact of anti-infective-treated central venous access devices on the incidence of catheter-related blood stream infections. The first is… Niël-Weise, B.S., Stijnen, T. and van den Broek, P.J. (2008) Anti-infective-treated central venous catheters for total parenteral nutrition or chemotherapy: a systematic review. The Journal of Hospital Infection. 69(2), p.114-23. [...]
Medical Device Alert MDA/2008/051
The MHRA have issued a medical device alert (MDA/2008/051) which concerns the Kimal safety fistula needle. Kimal is aware of the potential for the unintentional retraction of the cannula into the protection sheath, which can result in exsanguination. As a result, Kimal is recalling all lots of the device. Click here to view the alert.
Intraosseous access in children
This article reviews the safety of powered intraosseous devices in pediatric patients. The authors state that ”the rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients” (Horton and Beamer 2008). Horton, M.A. and Beamer, C. (2008) Powered intraosseous [...]
Fist clenching during phlebotomy
The authors describe the potential impact of fist clenching during blood sampling upon the incidence of pseudohyperkalaemia. Bailey, I.R. and and Thurlow, V.R. (2008) Is suboptimal phlebotomy technique impacting on potassium results for primary care? Annals of Clinical Biochemistry. 45(3), p.266-269. Abstract: Background: Pre-analytical problems causing pseudohyperkalaemia have been highlighted previously. These include transit time and [...]
Epidural and IV confusion
In 2006 Jasmine Gant, 16, died following a mistake by nurse Julie Thao. Jasmine died following an inadvertent disconnection of her epidural during childbirth. Thao mistakenly attached the epidural to the IV device. The Wisconsin State Journal state that progress has been made to increase the safety associated with tubing connections, but obstacles continue. “It’s inching [...]
Revised EU monographs for heparin
The MHRA have reported a revision of European Pharmacopoeia monographs for heparin. “Following increased reports of adverse events associated with heparin preparations in the United States of America and some European countries, the European Pharmacopoeia monographs for Heparin Calcium (0332) and Heparin Sodium (0333) have undergone rapid revision and implementation in order to strengthen the level of testing required [...]
Redesigned peripheral IV catheter
The launch of the VantageCath has seen a radical redesign of the traditional peripheral IV catheter. Designed to not only prevent unexpected needlestick injuries, but also to eliminate the spillage of blood during the IV placement. The device is a product of a firm called Advantage Medical Devices from Solana Beach, CA. Advantage Medical Devices state: “The [...]
Needle and syringe redesigned
Christopher Holden has won an award redesigning the traditional needle and syringe. The ‘MediDome’ aims to eliminate needlestick injuries, simplify the process and speed up patient treatment. Christopher has won a National Patient Safety Award of £3000 and NCR Internship worth £4000 for a duration of four weeks. Christopher explains how the product works: “A [...]
Pediatric CVAD blood sampling
Kathleen Adlard examines the issues of central venous access device blood sampling from pediatric cancer patients. Adlard, K. (2008) Examining the Push—Pull Method of Blood Sampling From Central Venous Access Devices. Journal of Pediatric Oncology Nursing. 25(4), p.200-207. Abstract: “The placement of a central venous access device (CVAD) has revolutionized supportive care for pediatric cancer patients. [...]
AVA conference brochure
The Association for Vascular Access (AVA) have published the brochure for the 22nd Annual Scientific Meeting. The Association for Vascular Access will stress the value of a multidisciplinary approach as AVA demonstrates its leadership role in all aspects of vascular access. This conference incorporates multiple venues for vascular access education and networking. Through general sessions outlining cutting-edge technology along with research and scientific-based [...]
Cannula insertion documentation
Our recent IVTEAM poll has just finished. We asked the question “Should you record lot/batch numbers following cannula insertion”? 87% of IVTEAM visitors felt that it was important to record lot/batch numbers. Thank you to all who voted. Our new poll has just been launched. IVTEAM are now asking “When securing a peripheral cannula do you use [...]
Fatal injection of ranitidine
This case study describes the case of a 51-year-old man with negative anamnesis for allergic events, who died suddenly after the intravenous administration of one phial of Zantac(R) 50mg prescribed as a routine post-surgical prophylaxis for stress ulcer. Oliva, A. et al (2008) Fatal injection of ranitidine: a case report. Journal of Medical Case Reports. 2, p.232. [...]
Wristband warnings
IVTEAM have reported before on the use of wristbands in healthcare (click here). Well, its back in the press and yes we still have a problem with the ‘Do Not Resuscitate’ wristband! BroMenn Healthcare and St. Joseph announced Monday that the two health care organizations have collaborated on color-coded wristbands to immediately alert doctors and hospital [...]
Vascular access in court
Four condemned prisoners are attempting to stop executions in Mississippi. They say the state’s method of lethal injection is unconstitutional because it might cause pain. The inmates have issues with numerous parts of the process. One particular issue that they highlight is that they believe the insertion of the intravenous needle could also be a [...]
ASHP’s IV Safety Summit
ASHP and its partners will gather healthcare practitioners, thought leaders and medication-safety experts from around the nation to achieve consensus on actions that bring about real and lasting improvements in the use of IV medications, protecting patients from harm and death due to errors. Summit Goals Achieve consensus on an initial set of broadly applicable [...]
ANTT conference
The Aseptic Non Touch Implementation team have announced the 1st National Conference on Aseptic Non Touch Technique (ANTT) on the 29th September 2008 – London, UK. This National Conference for ANTT will present important latest evidence and developments from leading NHS hospitals. Speakers include; Dr Carole Pellowe will update on EPIC2 progress and explain how ANTT is [...]
Neonatal IV dressing
Neonatal IV dressing technique is under represented in the literature. This article attempts to redress the balance. Sharpe, E.L. (2008) Tiny Patients, Tiny Dressings: A Guide to the Neonatal PICC Dressing Change. Advances in neonatal care. 8(3), p.150-62. Abstract: Advances in neonatology now support the survival of the tiniest of infants. The peripherally inserted central catheter [...]
External jugular Groshong catheter
This article attempts to demonstrate the efficacy and safety of insertion of a Groshong catheter via the external jugular vein (EJV) for central vein access. Ishizuka, M., Nagata, H., Takagi, K., Horie, T., Furihata, M.., Nakagawa, A. and Kubota, K. (2008) External jugular Groshong catheter is associated with fewer complications than a subclavian Argyle catheter. European surgical [...]
PICC’s for children with cancer
This article describes PICC’s as a convenient, reliable vascular access device for children with cancer. Abedin, S. and Kapoor, G. (2008) Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatric Blood & Cancer. 51(2), p. 251-5. Abstract: BACKGROUND: A long term venous access device is essential in [...]
VisIV container reduces IV waste
Kennedy Health System recently announced that it has implemented the VisIV flexible intravenous container.
Extravasation injury baby
Baby Lai Yok Shan, who lost her left arm soon after birth when it turned gangrenous, turned one year old on
Baby died following extravasation
A coroner has ruled doctors at a Plymouth hospital were not to blame for the death of a two-week-old premature baby who died after the contents of her feeding tube leaked. A paediatric expert at the inquest, Professor Peter Fleming, agreed with the doctors who treated Brooke, that the feeding fluid had led to a chemical [...]
Marines learn IV access
Marines of 9th Engineer Support Battalion, 3rd Marine Logistics Group, practiced saving lives during the Combat Lifesavers Course. With a limited number of corpsmen in the field, Marines often have to rely on fellow Marines to provide initial care. That’s one reason why deploying units must be 100 percent combat lifesaver certified, according to Petty [...]
Child cannulation competencies
The RCN have available an education and training competency framework for peripheral venous cannulation in children and young people. The framework identifies the competencies,learning outcomes and the indicative content necessary for education and training programmes to meet the needs of children and young people.It aims to support consistent curriculum and practice development so that practitioners can develop and,maintain the ability to carry [...]
Syringe disconnection alert
The MHRA have issued an alert warning of inadvertent syringe disconnection. The issue is with procedure packs from various manufacturers which contain BD Medical Surgical Systems 2ml, 5ml and 10ml Plastipak Luer slip syringes. The warning points to potential for the BD Luer slip syringes supplied in procedure packs to spontaneously disconnect or fail to maintain [...]
Potential infusion error
The MHRA have issued an alert warning of potential infusion device drug error when using the Smiths Medical Graseby Omnifuse and Omnifuse PCA syringe pumps. The MHRA have warned of the possibility of patients being given an additional/unnecessary infusion when syringes are changed or infusions restarted when using DrugPro software. If the user selects – but [...]
Fatal intrathecal drug error
The Times of India reports that a 37-year-old engineer died on Wednesday morning, allegedly because of intravenous chemotherapy mistakenly given via the intrathecal route. The Times of India writes “On June 18, an anaesthetist — in the absence of a doctor — pushed a chemotherapy injection into Kuntal Chowdhury’s spinal cord. The injection was supposed to be [...]
Central catheter infection rates
New York city and New York state hospitals report catheter related blood stream infection rates. In New York City, 2.8 out of 1,000 central lines at medical intensive care units resulted in infections, compared to 3.6 upstate. In the city, another 2.7 out of 1,000 central lines in surgical ICUs resulted in infections, compared to [...]
High tech clean rooms
Hamad Medical Corporation has established the first pharmacy manufacturing clean rooms in the Middle East. The clean rooms are being established in a bid to improve pharmaceutical activities within the corporation. Fully automated chemotheraphy machines have been installed in these rooms, which ensure sterile products, reduce human error and infections to patients. Opening three such rooms yesterday [...]
Heparin overdose
A Corpus Christi hospital says 14 babies in its neonatal intensive care unit received overdoses of the Heparin. Christus Spohn Hospital South CEO Bruce Holstein says the error in the dosage of the medicine – used to flush intravenous lines to prevent blood clots from forming – was discovered Sunday night by hospital nurses. He says [...]
IVTEAM beat nursing shortage
Dan Ast is a member of the IV therapy team at Via Christi Regional Medical Center-St. Joseph Campus. As the nursing shortage worsens, Via Christi has adopted new ideas to make up for vacancies, things like the specialization of nurse tasks like those carried out by Ast and his team. His bosses say these ideas [...]
Fresenius acquire APP
Fresenius will acquire APP Pharmaceuticals, the US manufacturer of intravenous drugs, for $3.7 billion (£1.9 billion) in a deal that will help the German dialysis specialist break into the American market. APP, the second-largest maker of intravenous generic drugs in the United States, will complement Fresenius’ Kabi unit, a global supplier of infusions and gastric tube [...]
FDA update on heparin
The FDA have recently released a video update on the contaminated heparin issue. Over the past several months, FDA has been alerting healthcare professionals and the public about medical products that may contain contaminated heparin, which has been associated with a number of serious adverse events. Here is an update and recommendations on this continuing [...]
Vascular access infection control
This article highlights the importance of education in infection prevention. The authors illustrate that procedures may be common place, however they discover that the delivery of education related to vascular access and infection prevention is limited. Higgins, M. and Evans, D.S. (2008) Nurses’ knowledge and practice of vascular access infection control in haemodialysis patients in the republic of [...]
Neonatal procedure pain
A paper in JAMA examines painful and stressful procedures in neonates cared for in Parisian intensive care units, and comes to the conclusion that on average, each baby undergoes about 10 painful procedures a day, the majority with no analgesia at all. Many of these are repeated failures of common procedures such as insertions of intravenous [...]
