Insulin medication errors

Intravenous literature: News-Medical.net report “Analysis of data related to insulin medication errors and a local Read more

Infusion safety system

Intravenous products: OneMedPlace.com report “Intravenous (IV) drugs leave a huge margin for human Read more

Safety needle device comparison

Intravenous literature: Tosini, W., Ciotti, C., Goyer, F., Lolom, I., L’Hériteau, F., Abiteboul, D., Pellissier, G. and Read more

Adverse transfusion events

Intravenous news: InfectionControlToday.com report “The Centers for Disease Control and Prevention (CDC) has Read more

Needlestick injury psychological harm

Intravenous news: The Court of Appeal recently made a judgment in the case Fryers vs Belfast Health and Social Read more

Gentamicin errors

Intravenous news: NPSA report “Patient safety incidents have been reported involving administration of gentamicin at the Read more

Supporting needlestick prevention

Intravenous news: eGovMonitor.com report “The Employment and Social Affairs Committee today backed an Read more

Matching Michigan funding

Intravenous news: The National Patient Safety Agency (NPSA), in collaboration with the Intensive Care Society and the Read more

Parenteral syringe oral drug error

Intravenous news: The FDA report “A recent report by the Institute for Safe Medication Practices says that despite past Read more

Central-line infection reduction

Intravenous news: YorkPress.co.uk report “Bug-busting health workers are in the running for a national accolade. Critical care staff at York Read more

Heparin flush lawsuit

Intravenous news: attorneyatlaw.com report “Relatives of a Texas man who died after receiving a contaminated dose of the blood Read more

Patient identification errors

Intravenous literature: Henneman, P.L., Fisher, D.L., Henneman, E.A., Pham, T.A., Campbell, M.M. and Nathanson, B.H. (2009) Read more

Safe intravenous (IV) administration

Intravenous products: Medscape.com report “At the American Society of Health-System Pharmacists (ASHP) 44th Midyear Clinical Read more

Hep C outbreak report published

Intravenous news: InfectionControlToday.com report “According to a report released by the Centers for Disease Control and Prevention Read more

Get smart with sharps

Intravenous news: The Coast News report “A new campaign promoting the responsible disposal of needles was launched on Read more

Needlestick legislation expansion

Intravenous news: The Government of Ontario report “Ontario is increasing protection for health Read more

IV drug mix-ups

Intravenous news: The NHS is threatening to stop using current drug equipment in a bid to get firms to start making safer Read more

10,000 needlesticks each year in home care

Intravenous news: eScienceNews.com report “Patients continue to enter home healthcare ‘’sicker and quicker,” Read more

Reusing single-use IV supplies

Intravenous news: Broward Health report “Broward General Medical Center is reviewing one nurse’s practice Read more

CareFusion IV pump alert

Intravenous products: CareFusion is alerting healthcare professionals about a number of safety problems with several models Read more

Hospira IV pump alert

Hospira, Inc. has issued an alert about a number of the company’s medical devices that have defective AC Read more

Heparin safety changes

Intravenous news: PRnewswire.com report “The U.S. Food and Drug Administration today alerted health care Read more

Promethazine FDA Boxed Warning

Intravenous news: FDA is requiring a Boxed Warning for promethazine hydrochloride injection, USP products to better Read more

Topical epinephrine injection death

Intravenous news: FDA report “The Institute for Safe Medication Practices (ISMP) recently cited a report from the ISMP Canada Safety Bulletin about the death of a patient who was accidentally injected with topical epinephrine. The attending surgeon and nurse mistakenly thought the syringe they were using contained lidocaine with epinephrine 1:100,000.

ISMP noted an earlier case in which a child died from cardiac arrest after his ear was infiltrated with a syringe containing epinephrine 1:1,000 that had been filled from an open cup. The physician mistakenly assumed that the solution in the cup contained lidocaine with epinephrine 1:100,000.”

Click here for the full report.

Insulin pump alert from FDA

Intravenous products: FDA report “In July, Medtronic recalled certain infusion sets which are used with the company’s Mini-Med Paradigm insulin pumps to deliver insulin to diabetic patients. Because of a manufacturing error, the vents on these sets may clog and then fail to equalize the air pressure in the reservoir compartment with the surrounding atmosphere. If this happens, the pump could deliver too much or too little insulin to the patient, and that could lead to serious injury or death.”

Click here for the full report.

Safety IV device demand grows

Intravenous products: InfectionControlToday.com report “A new market research report, “U.S. Infection Prevention Products & Services,” from Reportlinker.com projects that the total demand for infection prevention products and services will increase 4.5 percent annually through 2013. Growth will partially reflect the impact of new government legislation and changing health insurance reimbursement policies aimed at reducing the incidence of healthcare-acquired infections (HAIs). Gains will also be driven by efforts to reduce the incidence of HAIs in healthcare and life science institutions, prompting upgrades to standards involving patient and staff hygiene and protection, facility cleaning and disinfection, device and instrument sterilization and medical waste collection and disposal.

According to the report, safety-enhanced devices for IV and injectable drug delivery and in vivo fluid withdrawal, along with high-quality apparel, textiles and disinfectants for surgical procedures, will remain the top selling groups of infection prevention products. An increasing percentage of the syringes, catheters, IV administration sets, blood collection supplies and other disposable sharp instruments employed by the medical community will incorporate safety components designed to prevent accidental needlesticks and associated infections after use.”

Click here for the full story.

Infusion error deaths

Intravenous news: ISMP.org report “ISMP recently learned about the tragic deaths of two 6-year-old children stemming from severe postoperative hyponatremia. The fatal events occurred at two different hospitals. In at least one of these cases, it is clear that the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in acute hyponatremia secondary to free water retention (also called water intoxication, which is described below). Postoperative children are at high risk for developing hyponatremia, and many fatalities from this disorder have been reported in the literature. When the serum sodium concentration rapidly falls below 120 mEq/L over 24 to 48 hours—as in the two events described below—the body’s compensatory mechanism is often overwhelmed and severe cerebral edema ensues, resulting in brainstem herniation, mechanical compression of vital midbrain structures, and death.”

Click here for the full article.

IV device identification

Intravenous news: The Institute for Safe Medication Practices report “A patient with a low potassium level was due to receive three sequential, hour-long infusions of highly concentrated potassium chloride 20 mEq in minibags. A primary IV of 0.9% sodium chloride was infusing so the patient’s nurse attached a secondary IV set to the first potassium chloride minibag, connected it to the primary line, and began infusing the solution via a pump. She came back to the patient’s room when the second dose was due and noticed the potassium solution was flowing quickly into the drip chamber. She then realized the solution was flowing into the primary IV bag rather than the patient”.

Click here for the full item.

Purple not an IV or enteral standard

Intravenous news: The Institute for Safe Medication Practices report “Purple is not an official standard for either enteral feeding equipment or PICC lines.” They describe “an epileptic patient who was supposed to receive oral KEPPRA (levetiracetam) liquid via a PEG tube instead received it IV via a Bard PowerPICC (peripherally inserted central catheter) line. An oral Baxa amber syringe that held the levetiracetam did not connect properly to the hub of the PICC line, however it could be held easily against the opening for the injection. It’s possible that the experienced nurse who incorrectly gave the drug IV was confused by a purple color system available from Covidien for enteral feeding equipment. The color is identical to the purple coloring used for the patient’s Bard PowerPICC line. Learn more about preventing errors like this in your facility in the newsletter”.

Click here for the newsletter.

Click here for more information from ASPEN.

RCN comments on sharps injury agreement

Intravenous news: The Royal College of Nursing today welcomed the signing of a joint agreement by European Federation of Public Service Unions (EPSU) and the European Hospital and Healthcare Employers Association (HOSPEEM). This is an EU-wide agreement which the RCN has played a key role in bringing about to prevent one million medical sharps injuries per year. Dr Peter Carter, Chief Executive of the Royal College of Nursing (RCN), said:

“Around half of nurses in the UK have been injured by a needle or sharp and we are delighted that the voice of our members has been heard in Europe on this issue. Nurses work in fear of needlestick injuries and, while the deal is welcome, we are concerned that it might take a number of years to be implemented in the UK. We are calling for speedy implementation of these measures in order to end the stress, trauma and serious medical consequences of these preventable accidents. It is vital that more people are not injured while we wait for safer practices to reach the workplace.”

Dr Carter continues “It is very clear – needle policies, training and investment in safer needles can help prevent these accidents from happening in the first place. Nurses must also receive proper support from their employers when they sustain an injury to prevent the feelings of stress and isolation that often accompany such trauma. By making these changes and safeguarding the health of all staff, we can improve patient care in the UK and throughout Europe.”

EU sharps safety agreement signed

Intravenous news: The European Hospital and Healthcare Sector Social Partners – The European Federation of Public Service Unions (EPSU) represented by the President of EPSU health Committee, Karen Jennings and the European Hospital and Healthcare Employers’ Association (HOSPEEM) represented by General Secretary, Godfrey Perera today signed a European agreement, which is set to prevent medical sharps injuries for the whole health workforce in Europe.

Click here for the full press release.

Click here to view the agreement text.

Click here to view a video of the signing.

Fifty percent of injections unsafe

Intravenous news: PlusNews.org report “Injections and needles are still not being used properly in African health Read more

Needlestick prevention delay

Intravenous news: The Nursing Times report “NHS Employers is unlikely to recommend that the NHS implement new European guidelines on needlestick injuries until at least 2011″.

“Speaking last week Karen Jennings, Unison’s head of health, called on the NHS to ‘take the initiative’ and ‘start using safer needles and adopting the new prevention guidelines across the UK now’.

“But a spokesperson from NHS Employers told Nursing Times that the NHS was already compliant with high standards of needlestick and sharps usage, and that it would not be taking immediate action following the agreement”.

Click here for the full story.

Needle safety legislation for UK

Intravenous news: The Nursing Times report “The European Federation of Public Service Unions and the European Hospital and Healthcare Employers Association yesterday announced an EU-wide agreement on measures to make needles safer, which are expected to become legislation by the end of the year.

Karen Jennings, UNISON’s head of health, who led negotiations on behalf of the union federation, said: ‘Subjecting thousands of NHS workers every year to the terror of dirty needles is unnecessary and inhumane, when safer needles are available and cost very little more”.

Click here for the full story.

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Safer needles in the European Union

Intravenous news: The Nursing Times report “UK hospitals will have to introduce self-resheathing needles under European Union health and safety legislation on reducing needlestick injuries. A landmark agreement on the safer use of needles to prevent injury among hospital staff was set to be announced on 9 June at the European Public Services Unions annual congress in Brussels, Belgium.

The agreement has been made between the European Public Services Unions – which represents the majority of health trade unions across the EU including Unison, the RCN and the RCM – and Hospeem which represents hospitals and healthcare employers across Europe, including the NHS Confederation.

It is expected to become EU health and safety legislation before the end of the year. As a result, hospitals across the EU will soon be legally obliged to take action to prevent needlestick injuries to their staff”.

Click here for the full story.

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Misuse of IV fluid bags

Intravenous news: The Jamaica Gleaner reports “A nurse, who was attached to the May Pen Hospital, is facing a six-month suspension after a baby - born prematurely – died while under her care in August 2008″.

They continue “At one point, the child’s body temperature began to fall. It is alleged that the nurses used a microwave oven to heat bags containing intravenous fluid. These were then wrapped in towels and blankets before the child was placed on top of them… It is further alleged that at least one of the bags burst and the hot content burnt the child, resulting in its death”.

Click here for the full story.

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Contaminated heparin syringes

Intravenous news: chicagotribune.com report on a personal account of the tragic impact of contaminated heparin syringes on one family “Natalie Fullerton’s parents were thrilled to watch their year-old daughter bounce back from a double-lung transplant. Within months, she was mimicking her sister’s ballet poses and gleefully repeating the word “purple.”

Her father, Leslie, carefully tended to Natalie, following an intricate regimen to keep her healthy. After doctors implanted a tube in Natalie’s chest to give her intravenous medication, he dutifully used fluid-filled syringes to clean it.

Days later, the 29-month-old was back in a Texas hospital, breathless and feverish. Bacteria had infected her blood, the first in a cascade of complications over four months. In the end, Natalie died in her mother’s arms on March 12, 2008″.

Click here for the full story.

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Needlestick reference list

Intravenous literature: IVTEAM would like to present a ‘Needlestick Reference List‘. The list consists of references of Read more

Sharp safety poll

Intravenous news: New IVTEAM Poll launched “Should the mandatory use of sharps safety devices be made European law?”

Please vote in the IVTEAM poll box shown at the bottom right of every IVTEAM page.

More IV news at IVTEAM

Needlestick personal account

Intravenous news: “I felt a sharp sting. Looking down, I saw a small scarlet drop emerging from the tip of my left index finger. I had stabbed my finger against the needle I had just used to anesthetize Jean’s skin, a needle I still held in my right hand.

I stared at the tiny red bloom on my fingertip. And for a moment, I felt the floor beneath my feet give way, pulling everything — Jean, my heart, my work, my life — down with it. I stood there paralyzed, staring at the puncture wound on my fingertip and unable to stop the movie playing in my mind’s eye, a movie of a future like Jean’s”.

Click here for the full article from Dr Chen following a needlestick injury.

Read the comments on this story on the Tara Parker-Pope on Health blog.

More IV news at IVTEAM

Possible heparin deaths

Intravenous news: The Chicago Tribune reports ‘Baxter International Inc. said medical care providers at a hospital in Delaware and U.S. health officials are investigating whether the deaths of two patients are linked to a brand of heparin blood thinner Baxter sells in intravenous bags.

The U.S. Food and Drug Administration said the situation “appears to be an isolated incident,” agency spokeswoman Karen Riley said this afternoon.

Use of Baxter’s heparin, a diluted form in pre-mixed bags used for a variety of blood thinning purposes, has been suspended by officials at Beebe Medical Center in Lewes, Del. since Friday. Adverse reactions were reported in five patients who had problems that included internal bleeding in the brain”.

Click here for the full news story.

Update on CNN 16th May 2009

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Medical Device Safety Calendar 2009

Intravenous news: The FDA report ‘FDA has received many reports of patient injuries and deaths when different device delivery systems are mistakenly connected to each other. These errors are often facilitated by fittings called Luer connectors, which allow different systems to be easily, but erroneously, connected. 

The 2009 Medical Device Safety Calendar is one of FDA’s efforts to help educate healthcare professionals about these dangerous misconnections. The calendar provides a graphic depiction of a variety of misconnection cases, coupled with recommendations from The Joint Commission on ways to prevent these types of errors. We hope the calendar will be posted as a year-long reminder to staff that these errors can occur in any clinical setting. We also urge clinicians to use the case synopses and recommendations as on-going training materials. They can be downloaded free of charge by going to the website. Clinical facilities may also request copies of the calendar while supplies last.

For more information from the FDA watch the video below.

Click here to view a pdf of the calendar.

Click here for the this item on the FDA website.

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Heparin error update from FDA

Intravenous news: The FDA report “The Institute for Safe Medication Practices (ISMP) points out that some multiple dose heparin vials have potentially confusing labels that could lead to dangerous overdoses. These vials, which contain 4 mL of heparin solution, are labeled “10,000 USP units/ 1 mL,” with the “10,000″ in larger print than the rest of the designation. Because of this, someone quickly reading the label could assume that the entire vial contains 10,000 units. Calculating the patient’s dose based on that mis-reading of the label could result in a fourfold overdose. 

To help avoid this potential hazard, ISMP suggests that hospitals consider whether they need heparin in vials that contain more than 10,000 units per vial”.

For more information from the FDA watch the video below.

Read the ISMP Medication Safety Alert! Is It Really Needed? January 15, 2009.

Read the link on the FDA website.

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IV Station from Health Robotics

Intravenous products: PharmacyEurope.net report that a “US medical technology firm has unveiled a robot designed to deliver accurate and efficient intravenous (IV) mixtures to patients in a safe and cost effective way. The IV Station from Health Robotics can automatically mix compounds while producing ready to administer IV doses in a variety of syringes, bags, vials, and tamper-evident caps.

The launch at the European Association of Hospital Pharmacists, in Barcelona, Spain, was also accompanied by a display of the company’s CytoCare, a pioneering chemotherapy IV robot.

Health Robotics said the new IV device was designed to minimise medication errors, and address high costs, lack of sterility and difficulties in maintaining adequate and trained staff. The firm has already reached agreements for the delivery of 16 IV Stations to medical facilities in countries across the globe, including the UK, Japan, Turkey and Italy”.

Click here for the full story on PharmacyEurope.net

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Safe IV injection technique

Intravenous news: OHS report on APIC tips for reducing infection risk in outpatient clinics. One aspect they focus upon is safe intravenous (IV) injection techniques, stating

“In 2008, more than 60,000 people were notified of their risk of hepatitis C due to reuse of syringes at a Nevada endoscopy clinic. There have also been reports of reuse of finger stick devices and insulin injection devices meant for individual use. Reused syringes can transport tiny fragments of a patient’s blood to the next medication vial, potentially infecting other patients. Syringes and needles must be used one time only. Before receiving an injection, ask if the needle and syringe have been newly opened for you. Inquire if the center uses single-dose vials of medication or multi-dose vials with strict controls. If they use multi-dose vials, ask if they unwrap a new syringe and needle for each dose of medication. If you will receive intravenous fluids, ask that they do not use the bag for other patients or set up the intravenous tubing until they are ready to administer to you”.

Click here for the full story on OHSonline.com

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HepC after needlestick

Intravenous literature: Gruener, N.H., Heeg, M., Obermeier, M., Ulsenheimer, A., Raziorrouh, B., Diepolder, H., Zachoval, R. and Jung, M.C. (2009) Late appearance of hepatitis C virus RNA after needlestick injury: necessity for a more intensive follow-up. Infection Control & Hospital Epidemiology. 30(3), p.299-300.

Abstract not available.

More IV news at IVTEAM

Needlestick-prevention devices

Intravenous literature: De Carli, G., Puro, V., Studio Italiano Rischio Occupazionale da HIV (SIROH) Group and Jagger, J. (2009) Needlestick-prevention devices: we should already be there. Journal of Hospital Infection. 71(2), p.183-4.

Abstract not available.

More IV news at IVTEAM

Needlestick injury advice

Intravenous literature: O’Connor, M.B. (2009) Needlestick injury advice in the UK and Ireland. Journal of Hospital Infection. 71(2), p.185-6.

Abstract not available.

More IV news at IVTEAM

Reducing needlestick injuries

Intravenous literature: Gabriel, J. (2009) Reducing needlestick and sharps injuries among healthcare workers. Nursing Standard. 23(22), p.41-4.

Abstract:

The risk of needlestick or sharps-related injuries to healthcare staff with statistical data about numbers of injuries, and how blood-borne viruses can be transmitted. Prevention and management of sharps injuries is discussed.

More IV news at IVTEAM

Needlestick injury with introcan

Intravenous literature: Pham, M. and Neustein, S.M. (2009) A needlestick injury with the introcan safety needle. Anesthesia & Analgesia. 108(2), p.669-70.

Abstract not available.

More IV news at IVTEAM

Intensive care drug errors

Intravenous literature: The BBC news website reports “Errors in the administration of injected medication in intensive care units occur frequently, a study across 27 countries suggests. Austrian researchers collected data on more than 1,300 patients, 200 of them in the UK, over a 24-hour period. Of the 441 patients affected, seven suffered permanent harm and five died partly because of the error, the British Medical Journal reported”.

The report continues “Medical staff often cited stress and tiredness as contributing factors. Data was collected by researchers from Rudolfstiftung Hospital from a total of 113 intensive care units, of which 17 were in the UK. Nearly half of the affected patients suffered more than one mistake during the period covered. The most frequent errors were related to the wrong time of administration and missing doses altogether”.

Click here for the full story on BBC news.

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Baxter IV pump alert

Intravenous products: Baxter International Inc. has found more problems with its long-troubled “Colleague” intravenous fluid pumps, including software glitches the company needs to fix and user problems it has advised customers to avoid.

The Deerfield, Ill., company sent a letter to customers on Jan. 23, a day after its fourth-quarter earnings call, to highlight the newfound issues with its entire roster of 275,000 Colleague pumps around the world, including pumps the company issued during remediation efforts to fix other problems. Colleague pumps were first pulled in 2005 amid a host of problems and defects linked to some deaths.

The latest problems came under the spotlight Wednesday when Baxter said the U.S. Food and Drug Administration had assigned a “Class 1″ recall status to the matter, which is the agency’s most serious recall classification.

Click here to view the full news item on CNNMoney.com

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Alaris IV pump alert

Intravenous products: This Safety Alert informs you about a potential risk when the Alaris® PCA module (model 8120) is used with the Alaris® PC Unit (model 8000 and model 8015) with software versions 8 through 9.1. The Alaris® PCA module can potentially infuse above or below the intended infusion dose.

Click here to view the full safety notice.

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Needlestick reduction

Intravenous products: A Sheffield-based healthcare company, B Braun Medical, is helping to prevent needlestick injuries to NHS staff. The company’s patented safety device, which eliminates the risk of being accidentally stuck or scratched by needles when delivering medication through a cannula, has already been snapped up by more than 70 UK NHS trusts.

And those who have adopted the technology say they are cutting down on injuries as a result. At Manchester Royal Infirmary, for example, there was an average of 19 needlestick injuries every year, but there have been none since the introduction of the Vasofix and Introcan safety devices.

Click here for the full press release.

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Alteplase dosing error

Intravenous products: The FDA state that in a recent report, the Institute for Safe Medication Practices warned about the possibility of prescribing and administering the wrong dose of alteplase when the indication for the drug is not specified.

ISMP described a case of a patient in an interventional radiology department who suffered respiratory arrest from a pulmonary embolism. The physician in charge of the radiology procedure called a code and requested Activase 100 mg IV. The pharmacist who responded to the code called the IV admixture staff and asked for tPA, or tissue plasminogen activator, a synonym for alteplase.

Because the call came from the radiology department, and because the prescribed dose and the intended use were not communicated, the pharmacy staff did not realize that the drug was intended to treat a pulmonary embolus. Instead, they assumed that the alteplase was intended to restore catheter function, so instead of the 100 mg dose that had been prescribed, they dispensed 2 mg of alteplase. 

The physician running the code assumed the syringe he received contained the correct dose and administered it, which gave the patient a 50-fold underdose. The patient died, although it’s not clear what impact, if any, the medication error had on his death.

Click here for the full alert.

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IV pumps in home care

Intravenous news: In a report published today, the Netherlands Health Care Inspectorate writes there is inadequate collaboration between professionals involved in the use of IV pumps in home care.

The inspectorate argues that the lack of collaboration between doctors, nurses, home care organisations and suppliers of medical equipment can lead to dangerous situations in which patients receive too little or too much medication.

In the past two years, 26 people died in hospital as the result of incorrect use of intravenous drips; there are no figures available about the number of deaths in home care.

Click here for the full story.

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Syringe recycling scandal

Intravenous news: Modasa’s deadly Hepatitis-B trail has led investigators to a major medical waste recycling racket in Ahmedabad’s own backyard. A whopping 50 tonnes of biological waste, including syringes and needles, which has been impounded, could expose the city and the whole state to the threat of not just Hepatitis-B, but other deadly infections, spread through intravenous treatment. 

Usually such waste has to be segregated and destroyed in an incinerator. But these were probably to be repackaged and sold.

Update on the Times Online – 10th March 2009.

Click here for the full story.

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Gemstar infusion system

Intravenous products: Hospira, Inc., a global specialty pharmaceutical and medication delivery company, today announced the  introduction of the with GemStar(TM) Infusion Suite software, an advanced version of the market-leading, multi-application, GemStar pump. The GemStar SP infusion system is designed to help caregivers better incorporate patient safety best practices right at the patient’s bedside.

GemStar SP incorporates GemStar Infusion Suite software, a stand-alone personal computer (PC)-based application designed to enhance safe and efficient medication administration. In an effort to help clinicians combat the 1.5 million medication errors that occur annually(1), GemStar SP allows healthcare facilities to tailor the pump to meet specific clinical objectives.

The compact and portable pump has configurable settings to help streamline the programming process for clinicians and provide flexible drug protocols with hard limits to help prevent medication errors. GemStar also offers several security features including four keypad lockouts, integral set-based free flow protection and mandatory confirmation screens, to help minimize the risk of medication delivery errors.

Click here for the full press release.

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Nerve damage following IV

Intravenous news: The Eastern Regional Health Authority (ERHA) has been sued by a 62-year-old seamstress, who suffered injury to her hand after an intravenous needle was badly inserted while at the Sangre Grande Hospital three years ago.

Annette Hamilton Gladstone, of Red Hill, D’abadie, is a diabetic, and visited the hospital on May 6, 2006, for treatment of an associated condition.

In her claim filed by attorneys Anand Ramlogan and Cindy Bhagwandeen at the San Fernando High Court, Gladstone says a female doctor concluded that it was necessary to administer antibiotics. An intravenous line was inserted into her right hand, which allegedly became bluish in colour.

Gladstone says she noticed during the week following that she was unable to properly use her hand as it was painful, swollen, bruised and there was a loss of sensation. She visited the Port of Spain General Hospital on May 15, 2006, and a clinical examination of her hand revealed that it was swollen, bluish, tender and cold. It was suspected that the condition arose out of a complication with the insertion of the intravenous needle, not into a vein but in the tissue of the arm. An operation was performed on May 16, 2006, to decompress the nerves on the hand and to drain the remaining antibiotic fluid.

Click here for the full story.

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Blood imports may increase

Intravenous news: UK safety advisers are considering increasing imports of blood to reduce the risk of further infections of variant CJD, the human form of BSE, through blood transfusions.

The move comes as the Health Protection Agency yesterday confirmed the first case of an NHS patient contracting the human form of BSE after being treated with infected blood products. The man, who was over 70, died from an unrelated condition after showing no symptoms of vCJD or any other neurological condition, but the infection was identified during a postmortem on his spleen.

Another four people are thought to have been infected by the long-incubating vCJD via blood transfusion before measures to remove more infective white cells were introduced a decade ago, but uncertainty remains about the size of the public health threat.

Increasing the importing of blood is one of the measures being considered by the government’s advisory committee on the safety of blood, tissues and organs (Sabto).

Click here for the full story.

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Reuse of sharps containers

Intravenous products: A recent survey on use and reuse of sharps containers by Novation, Irving, Texas, asked members of its two owner groups, VHA and University Health System Consortium (UHC), their views on the topic. The survey, released in late October 2008, showed 60 percent of materials managers, nurses, risk managers and other hospital officials consider reusable sharps containers to be safe, a major increase over Novation’s 2006 survey, when only 38 percent of respondents thought so.

This article first appeared in the January 2009 issue of Materials Management in Health Care.

Click here for the full story.

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Enteralok prevents IV errors

Intravenous products: A new range of enteral syringes has been launched by Sheffield based InterVene® Ltd. In recent years, numerous deaths have occurred by administering enteral medication via intravenous (IV) lines. The enteral syringe which was designed in UK, has been produced in response to National Patient Safety Agency (NPSA) guidelines aimed at preventing maladministration of enteral medication via IV routes. 

The syringe employs a ‘reverse luer’ or ‘female luer’ tip which cannot be interchanged with a conventional IV syringe. A purple plunger immediately identifies the syringe as an enteral device and the words ‘Enteral / Oral’ are clearly displayed on the barrel.

Click here for the full press release.

Click here to visit the Enteralok website.

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Needlestick rates stuck

Intravenous news: Hospitals are stuck in a holding pattern in their sharps safety programs. Injury rate dropped implementation of safer sharps in 2001, but many facilities have since reached a plateau.

In about half the cases, the safety mechanisms were not activated, according to sharps injury databases, which indicates that either health care workers haven’t been instructed how to use the devices properly or they don’t feel comfortable activating them. Conventional devices still are commonplace, as well, the data indicate.

For example, for Massachusetts hospitals, the rate was 19.7 sharps injuries per 100 licensed beds in 2002. It dropped to 18.4 per 100 licensed beds in 2003, but then stayed the same in 2004.

Among hospitals in the EPINet network of the International Health care Worker Safety Center at the University of Virginia in Charlottesville, needlesticks declined significantly from 1999 to 2001, but then remained stable since then.

Click here for the full story.

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IV medication error payout

Intravenous news: A jury has awarded $5 million in a Pennsylvania malpractice lawsuit filed over a hospital medication error where a woman developed permanent brain damage after being given eight times the amount of sodium that her doctor prescribed to treat an electrolyte deficiency.

The lawsuit was filed by Mary Ellen Pfeifer against University of Pittsburgh Medical Center’s (UPMC) McKeesport Hospital in the Court of Common Pleas of Allegheny County, Pennsylvania. Pfeifer was admitted to the emergency room on December 21, 2006, and blood test revealed that she was suffering from confusion and difficulty walking caused by critically low sodium. The treatment plan called for her low sodium to be corrected at a rate of 125 cc per hour. However, due to a medication error by the hospital staff, she received 1000 cc in one hour.

Click here for the full story.
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IV glucose investigation

Intravenous news: A premature baby whose death is the subject of a police inquiry spent most of her short life at a Norfolk hospital. Poppy Read more

Safe Point device award

Intravenous products: A needle safety product emerged victorious at the third annual Banbury Innovation Award. Steve Cooley, a 43-year-old dentist from Adderbury, took home the prize after impressing the Dragons’ Den-style judging panel with his Safe Point needle remover. 

The device, which Mr Cooley envisages becoming, at the least, a part of every dentist’s surgery in the UK, safely removes used surgical needles from a syringe, avoiding the current risk of getting a ‘needle stick’ cut by doing it manually. 

Click here for the full story.

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Safe tube-feeding in hospitals

Intravenous news: As part of their commitment to safety, Nestle HealthCare Nutrition and the American Society for Parenteral and Enteral Nutrition, or A.S.P.E.N., today announced the launch of a new initiative to promote safe tube-feeding in hospitals.

The “Be A.L.E.R.T.” campaign is designed to raise awareness of key steps that should be taken in order to administer tube feedings more safely and reduce the risk of tubing misconnections. The program complements the A.S.P.E.N. Enteral Nutrition Practice Recommendations, a comprehensive set of safety guidelines issued this week during Clinical Nutrition Week.

Tubing misconnections caused by human error are a serious problem in our nation’s health-care facilities. A leading health-care organization reports that more than 300 people died or suffered serious injury from tubing misconnections between 2000 and 2004. (“Tubing Misconnections: A Perilous Design Flaw,” Materials Management in Health Care, November 2006: 36-39.)

“Solving this industry-wide problem requires all of us — hospitals, health-care professionals, regulators, quality improvement groups and manufacturers — to work together to raise awareness, implement design change and create the tools that nurses and others need to provide the highest-quality care possible,” said Carol Siegel, MS, RD, manager of professional services at Nestle HealthCare Nutrition, a unit of Nestle Nutrition. “This new education initiative is a significant step forward in our ongoing effort to improve patient safety.”

Click here for the full story.

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Sharps management in hospital

Intravenous literature: Aziz, A.M., Ashton, H., Pagett, A., Mathieson, K., Jones, S. and Mullin, B. (2009) Sharps management in hospital: an audit of equipment, practice and awareness. British Journal of Nursing. 18(2), p.92-98.

Abstract:

The safe handling and disposal of needles and other sharp instruments forms part of an overall strategy to protect staff, patients and visitors from exposure to blood-borne pathogens. As with many infection prevention and control policies, the assessment and management of the risks associated with the use of sharps is paramount, and safe systems of work and engineering controls must be in place to minimize any identified risks. The use of sharps in hospitals should be avoided where possible; when their use is essential, particular care is required in handling and disposal – if possible, use safer sharps devices. An audit of sharps management was undertaken to observe equipment, practice and awareness. The audit reported very positive results. However, some areas needed further review to improve practice. The infection control team implemented an action plan as a result of the audit and set about initiating measures for training and awareness. It is necessary to audit sharps management routinely to have an accurate assessment of current practice and prevent occupational exposure to blood-borne pathogens.

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Needlestick injuries reported to HSE

Intravenous news: Using Freedom of Information laws the Mirror.co.uk approached more than 150 NHS Trusts across England and found that in the first nine months of 2008 there were 85 incidents reported to the Health and Safety Executive as either the escape of dangerous substances or an accident involving a biological agent.

For example, at Manchester Royal Infirmary a staff member was pricked by a needle removed from an HIV-positive patient who had died. Of the 85 incidents, 40 involved staff pricked by needles with the potential to infect with a serious disease. Karen Jennings, of union Unison, said: “It is shameful to see just how many of these injuries are preventable.” Kim Sunley, for the Royal College of Nursing, said: “These instances are just the tip of the iceberg. We want to see legislation on needlestick injuries which makes it mandatory to provide safer needle devices that reduce the risk of injury.”

Click here for the full story.

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Intrathecal injection error

Intravenous news: Hospital equipment that was partly responsible for an 18-year-old’s death has still not been improved eight years after his death, MPs have been told. Leukaemia sufferer Wayne Jowett died after a chemotherapy drug was injected into his spine instead of his veins at the Queen’s Medical Centre in 2001.

At a meeting of the Commons Health Committee last week, Professor Brian Toft, who held an inquiry into the teenager’s death, told the committee that the connector he recommended in 2001 to prevent the mistake being made again had still not been produced. He told the committee: “My conclusions regarding Wayne were that there had been procedure failures. There was inadvertent human error (that was certainly the case) but there was also systems failure.” The connector Prof Toft recommended would stop intravenous needles being mistakenly connected to spinal needles.

Click here for the full story.

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HIV exposure and needlestick injury

Intravenous news: The Guardian reports that “Health care workers can get HIV if they prick themselves with a needle that’s been used on someone who has the virus. The chance that they’ll get HIV is very small. The chance of getting infected from a needlestick is less than 1 in every 300 accidents”.

They continue “Up to 2005, only five health care workers in the UK had become infected with HIV through their work. There’s also a chance that a further 14 people may have got HIV through a needlestick injury. But these people may have got HIV another way.”

Click here for the full story.

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Thirty patients test positive

Thirty out of approximately 1,000 former endoscopy and dental surgery patients of the High Prairie Health Complex have tested positive for hepatitis B, hepatitis C or HIV, health officials in High Prairie told CBC News on Wednesday.

The tests were ordered last fall after it was revealed single-use syringes had been reused at the health complex to inject medication into intravenous lines for years.

Final numbers are not in yet, and the statistics could simply be a reflection of the prevalence of these infections in the general population, according to Alberta’s acting chief medical officer of health, Dr. Gerry Predy.

“These infections they’re looking for … hepatitis B and C and HIV, are relatively common. So if you’re going to test hundreds of people, you will get some positives,” he said.

Click here for the full story.

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Smart infusion pumps

New “smart” drug pumps at Rice Memorial Hospital have been alerting nurses to errors — a dose of Dilaudid, a painkiller, that was accidentally programmed for 2 milligrams per hour instead of 0.2 milligrams, for instance — so that the error can be fixed before it reaches the patient.

Carnie Allex, director of pharmacy at the hospital, knows this because it’s one of the things being tracked in Rice Hospital’s efforts to improve patient safety.

Click here for the full story.

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Enteral feed mistaken for IV

An 87-year-old bedridden man suffering the aftereffects of a brain hemorrhage died after a serving of his liquid diet was mistakenly fed into a vein via an intravenous drip instead of a feeding tube into his stomach by an assistant nurse of a hospital in Ibaraki, Osaka Prefecture, police said.

The 45-year-old assistant nurse of Yukoukai General Hospital admitted the error, saying that she was too busy to realize her mistake. The police are investigating the case on suspicion of professional negligence resulting in death.

According to the hospital, the nurse mistakenly attached a 250-milliliter package of liquid meal to the man’s intravenous drip tube at around 4 p.m. on Jan. 2. Another assistant nurse noticed the error about 30 minutes later, and a doctor undertook procedures to try to save the man’s life, but the man died about 90 minutes later.

Read the original news story here.

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60,000 patients at risk for Hepatitis B

In the last decade, more than 60,000 patients in the United States were asked to get tested for hepatitis B virus (HBV) and hepatitis C virus (HCV) because healthcare personnel in settings outside hospitals failed to follow basic infection control practices, according to a new study by the CDC. 

This first full review of all the CDC investigations over the past 10 years of healthcare-associated viral hepatitis outbreaks appears in the Jan. 6, 2009 issue of the journal Annals of Internal Medicine.

“This report is a wake-up call,” said Dr. John Ward, director of CDC’s Division of Viral Hepatitis. “Thousands of patients are needlessly exposed to viral hepatitis and other preventable diseases in the very places where they should feel protected.  No patient should go to their doctor for healthcare only to leave with a life-threatening disease.”

In the United States, transmission of HBV and HCV while receiving healthcare has been considered uncommon. However, a review of CDC outbreak information revealed a total of 33 identified outbreaks outside of hospitals in 15 states, during the past decade: 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care facilities, resulting in 450 people acquiring HBV or HCV infection.

Patients were exposed to these potentially deadly diseases because health care personnel failed to follow basic infection control procedures and aseptic technique in injection safety. Reuse of syringes and blood-contamination of medications, equipment and devices were identified as common factors in these outbreaks.

Click here for the full news item.

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Infection prevention in outpatients

The Association for Professionals in Infection Control and Epidemiology (APIC) has issued a statement from Kathy Warye, CEO of APIC, in conjunction with an article being published in the January issue of the Annals of Internal Medicine about outbreaks of hepatitis B and C in outpatient clinics nationwide. The outbreaks are linked to unsafe injection practices. In the statement Warye addresses the need for increased infection prevention measures in outpatient settings and also APIC’s work with HONOReform, a national coalition formed to bring a halt to unsafe needle practices in outpatient centers. APIC is providing educational resources and expertise to this effort spearheaded by a hepatitis C survivor. As this year progresses, APIC will play an increasingly active role in monitoring legislation and educating the profession about safe injection practices.

Read the full story.

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Sharps injury protection

OSHA is making healthcare employers and employees aware of the sale of pre-filled syringes with fixed needles containing Fluvirin. Manufactured by Novartis, it is one of the 2008 seasonal flu vaccines. OSHA says the needles do not have engineered sharps-injury protections. The needles cannot be removed and replaced with products containing sheaths or shields.

Agency standards require needles used by healthcare workers who administer flu vaccine to have built-in antistick protection. While unprotected syringes pose a safety risk to employees, they do not affect the safety or efficacy of the vaccine in patients, says OSHA.

In response to an inquiry by the state safety agency, Novartis says that it replaced the fixed-needle syringes provided to public health departments in the state.

Click here for the full story.

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Top ten health hazards

In a recent Health Devices guidance article, ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care, reveals its 2008 list of the 10 most dangerous health technology hazards facing hospitals. The list—updated annually based on problems reported to and investigated by ECRI Institute—includes detailed descriptions of these hazards, as well as concrete information on how to avoid them. The article is being offered to healthcare professionals for free to help them understand and prevent these dangerous—and sometimes deadly—hazards.

In creating its annual list, ECRI Institute draws upon its 40 years of experience in investigating device-related incidents on behalf of healthcare facilities. And the clear, realistic recommendations offered within are distilled from dozens of in-depth articles and thousands of hours of expert analysis.

The top five health technology hazards identified in the 2008 list are:

1.      Alarm Hazards

2.      Needlesticks and Other Sharps Injuries

3.      Air Embolism from Contrast Media Injectors

4.      Retained Devices and Un-retrieved Fragments Left in Patients

5.      Surgical Fires

“Our list is based on serious technology safety concerns that can be prevented with appropriate attention and planning.  We hope that the list can help raise awareness about these problems, which should be on every hospital’s quality improvement agenda,” says James P. Keller, Jr., vice president, health technology evaluation and safety, ECRI Institute.

Click here for the full story.

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Free healthcare safety seminar

Intravenous conference: ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care, is offering a free educational breakfast seminar, “Hazard and Recall Management: Best Practices,” which will be held at ECRI Institute’s Headquarters in Plymouth Meeting, PA, on Wednesday, January 21, 2009.

The seminar is designed for hospital-based biomedical and clinical engineers, materials managers, risk managers, patient safety officers, and other health professionals responsible for responding to product alerts. The program is aimed at providing insight into identifying and locating affected healthcare products and putting an effective alert management process in place. 

“Managing hundreds of device recalls can be a daunting task for hospitals,” says James P. Keller, Jr., M.S., vice president, health technology evaluation and safety, ECRI Institute. “Through this seminar, participants will learn about ways to efficiently manage this process so that critical information about potentially dangerous products does not fall through the cracks.”

Seminar attendees will also learn the common missteps in the hazard and recall process, as well as how to establish executive-level buy-in to the alert process. In addition, the seminar will feature a panel/audience discussion on the five most common challenges of hazard and recall management.

Click here for the full story.

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Needlestick safety and prevention

After 20 years of intense regulatory and legislative activity and innovative changes to the design and handling of needles, U.S. healthcare workers are now significantly safer from needlestick injuries, according to a new study from the University of Virginia International Healthcare Worker Safety Center.

“Since the U.S. Needlestick Safety and Prevention Act was passed in 2000, American healthcare workers have benefited from an unprecedented level of protection from occupationally transmitted diseases,” says Janine Jagger, M.P.H., Ph.D., director of the Center and co-author of the study published in the December 8 issue of the Journal of Infection and Public Health.

Click here for the full story.

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Intravenous medication errors

Intravenous (i.v.) medication errors are twice as likely to cause harm to patients as medications delivered by other routes of administration (such as tablets or liquids), according to research commissioned by the American Society of Health-System Pharmacists (ASHP). This week, ASHP and leading healthcare organizations released recommended actions to prevent these potentially life-threatening events. 

The recommendations, published in the December 15, 2008, issue of the American Journal of Health-System Pharmacy, are a result of an IV Safety Summit convened this summer by ASHP. The Summit’s goal was to initiate actions that prevent harm and death from I.V. medication errors.

Because errors can occur anywhere in the I.V. medication-use process and effects can be immediate and serious, healthcare leaders and experts participating in the Summit agreed that the issue of i.v. safety urgently needs to be addressed. They achieved consensus on a core set of best practices that everyone should follow to ensure safe i.v. medication use.

Best practices included standardization of infusion concentrations and dosages; comprehensive standardized procedures for ordering, preparing, and administering i.v. medications; and the use of ready-to-administer doses whenever possible.

Participants identified actions that are needed to support universal adoption of best practices.

Actions recommended to be taken within the next one to three years include:

• Universally standardizing concentrations of “high-alert” i.v. medications (those most likely to cause harm if an error occurs) for all patients, including highly vulnerable patients, such as elderly, newborns, and those with chronic medical conditions;
• Streamlining the process to bring ready-to-administer standardized infusion concentrations to market; 
• Using “intelligent” i.v. pumps (e.g., those with safety features that help prevent unsafe rates and doses);
• Making the business case for i.v. safety to hospital leadership;
• Establishing multidisciplinary medication safety committees in hospitals to address the prevention of i.v. medication errors.

Long-term recommendations include:

• Using standardized, easily readable bar codes to verify i.v. drugs and doses; 
• Establishing multidisciplinary medication safety training for healthcare professionals; 
• Providing tools and resources to facilitate adoption of the i.v. safety practices; 
• Exploring new methods to stimulate error reporting and share lessons learned; and 
• Developing a framework for future research on i.v. medication safety.

Co-conveners of the Summit, along with ASHP, include the ASHP Research and Education Foundation, the United States Pharmacopeia, the Institute for Safe Medication Practices, the Infusion Nurses Society, the National Patient Safety Foundation, and The Joint Commission.

For more information about the summit and these recommendations, visit www.ashp.org/iv-summit.

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Double gloving

Wittmann, A., Kralj, N., Köver, J., Gasthaus, K. and Hofmann, F. (2009) Study of Blood Contact in Simulated Surgical Needlestick Injuries With Single or Double Latex Gloving. Infection Control & Hospital Epidemiology. DOI: 10.1086/593124

Abstract:

Objective.  Needlestick injuries are the most common injuries that occur among operation room personnel in the health care service. The risk of infection after a needlestick injury during surgery greatly depends on the quantity of pathogenic germs transferred at the point of injury. The aim of this study was to measure the quantity of blood transferred at the point of a percutaneous injury by using radioactively labeled blood.

Design.  This study was conducted to evaluate the risk of infection through blood contact by simulating surgical needlestick injuries ex vivo. The tests were conducted by puncturing single and double latex gloves with diverse sharp devices and objects that were contaminated with Technetium solution–labeled blood.

Results.  A mean volume of 0.064 μL of blood was transferred in punctures with the an automatic lancet at a depth of 2.4 mm through 1 layer of latex. When the double-gloving indicator technique was used, a mean volume of only 0.011 μL of blood was transferred (median, 0.007 μL); thus, by wearing 2 pairs of gloves, the transferred volume of blood was reduced by a factor of 5.8.

Conclusions.  The results revealed that double gloving leads to a significant reduction in the quantity of blood transferred during needlestick injury.

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Latex allergies

Graham Johnson reports that health and safety fears about latex allergy have prompted some NHS trusts and health boards to consider switching from surgical and examination gloves made of natural rubber latex (NRL) to synthetic alternatives. This strategy may be misguided.

The 2002 Court of Appeal support for a civil claim for damages by a nurse who had developed an allergy as a result of wearing NRL gloves (Dugmore vs Swansea NHS Trust) was incorrectly interpreted by some to mean that the use of NRL gloves should be outlawed.

Many NHS trusts still believe that the Health and Safety Executive (HSE) has banned NRL gloves. This is not the case, and some trusts may have over-reacted in deciding to switch to a latex-free policy.

Click here for the news release.

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Needlestick prevention award

“The award has been designed to reward and recognize health-care institutions that are committed to providing a safer environment to their patients and staff through the use of safety-engineered devices and programs,” said Kevin Egesborg, manager of healthcare worker safety for BD Canada, the company that presented the award, which also comes with a $500 grant to be used toward further health-care safety education.

From 2006/07 to 2007/08, the number of needle-stick injuries at OSMH dropped from 19 to 10. OSMH is one of 18 hospitals across Canada to win the award in 2008.

Click here for the full news item.

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Eye of the needle report

Research by the Health Protection Agency found more than three quarters of staff who have been put at risk of contracting hepatitis C had not been properly followed up.

Professor Mike Catchpole, Director of the Health Protection Agency’s Centre for Infections, said: “Although the numbers of reported healthcare workers infected with hepatitis C following their injury were few, these cases should never have occurred”.

” We all need to do everything we can to prevent occupational exposure injuries occurring. It is important for healthcare workers to report incidents of occupational exposure”.

“Testing and follow up checks are vital as infections can remain undetected for many years. However, our main aim should be doing everything we can to prevent occupational exposure injuries occurring in the first place”.

“Many incidents of occupational exposure can be prevented if there is proper adherence to standard precautions for the safe handling and disposal of clinical waste”.

No health professionals have contracted HIV through a needlestick injury since 1999.

The Eye of the Needle report is available at www.hpa.org.uk/needle

News report from the Telegraph.

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Sharp injury in OR

Myers, D.J., Epling, C., Dement, J. and Hunt, D. (2008) Risk of Sharp Device–Related Blood and Body Fluid Exposure in Operating Rooms. Infection Control & Hospital Epidemiology. 29(12), p.1139–1148.

Abstract:

Objective.  The risk of percutaneous blood and body fluid (BBF) exposures in operating rooms was analyzed with regard to various properties of surgical procedures.

Design.  Retrospective cohort study.

Setting.  A single university hospital.

Methods.  All surgical procedures performed during the period 2001–2002 ( ) were included in the analysis. Administrative data were linked to allow examination of 389 BBF exposures. Stratified exposure rates were calculated; Poisson regression was used to analyze risk factors. Risk of percutaneous BBF exposure was examined separately for events involving suture needles and events involving other device types.

Results.  Operating room personnel reported 6.4 BBF exposures per 1,000 surgical procedures (2.6 exposures per 1,000 surgical hours). Exposure rates increased with an increase in estimated blood loss (17.5 exposures per 1,000 procedures with 501–1,000 cc blood loss and 22.5 exposures per 1,000 procedures with >1,000 cc blood loss), increased number of personnel ever working in the surgical field (20.5 exposures per 1,000 procedures with 15 or more personnel ever in the field), and increased surgical procedure duration (13.7 exposures per 1,000 procedures that lasted 4–6 hours, 24.0 exposures per 1,000 procedures that lasted 6 hours or more). Associations were generally stronger for suture needle–related exposures.

Conclusions.  Our results support the need for prevention programs that are targeted to mitigate the risks for BBF exposure posed by high blood loss during surgery (eg, use of blunt suture needles and a neutral zone for passing surgical equipment) and prolonged duration of surgery (eg, double gloving to defend against the risk of glove perforation associated with long surgery). Further investigation is needed to understand the risks posed by lengthy surgical procedures.

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Saline error child dies

Two year old Emily Jerry died at Rainbow Babies & Children’s Hospital after a pharmaceutical technician prepared her intravenous treatment with a 23 percent saline solution instead of a typical mix of less than 1 percent, according to the Ohio State Board of Pharmacy.

Eric Cropp is the Rainbow pharmacist whose task it was to oversee the unidentified technician that mixed the chemotherapy solution. Cropp faces a hearing before the pharmacy board over the incident. If found negligent, he could be fined or lose his license. Cropp, of Bay Village, no longer works for the hospital and could not be reached for comment.

The technician, who no longer works at the hospital, faces no action because Ohio is one of 17 states that does not regulate pharmaceutical technicians.

Click here for the full story.

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Needlestick in a general hospital

Zhang, M., Wang, H., Miao, J., Du, X., Li, T. and Wu, Z. (2008) Occupational exposure to blood and body fluids among health care workers in a general hospital, China. American Journal of Industrial Medicine. 10.1002/ajim.20645

Abstract:

Objectives: To understand current status of occupational exposure to blood and body fluids (BBF), and awareness of knowledge about occupational bloodborne pathogen exposures and universal precaution among hospital-based health care workers (HCWs).

Methods: A cross-sectional study was conducted during April to May 2004 to study incidence of occupational exposure to BBF among 1,144 hospital-based HCWs.

Results: The total incidence and the average number of episodes exposure to BBF was 66.3/100 HCWs per year and 7.5 per person per year in the past year, respectively. The incidence (per 100/HCWs per year) and the average number of episodes (per HCW per year) of percutaneous injury (PCI), mucous-membrane exposure (MME), and exposure to BBF by damaged skin was 50.3 and 1.8; 34.4 and 1.7; and 37.9 and 4.0, respectively. The leading incidence and the average number of episodes of PCI occurred in delivery room (82.6 and 1.8). The highest percentage of PCI’s that occurred during the previous 2 weeks occurred during a surgical operation (22.8%). Of all sharp instruments, the suture needle contributed the highest percentage of PCI’s (24.7%) among HCWs in the last 2 weeks. Over two-thirds (68.3%) of respondents were immunized with Hepatitis B vaccine; less than one-half (47%) of HCWs wore gloves while doing procedures on patients. The respondents demonstrated a lack of knowledge regarding transmission of bloodborne diseases and universal precautions.

Conclusions: Risk for potential exposure to BBF appears high in HCWs, and almost all of episodes are not reported. It is urgent to establish the Guideline for Prevention and Control of Occupational Exposure to Bloodborne Pathogens among HCWs. 

American Journal of Industrial Medicine.

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Occupational blood exposure

Leiss, J.K., Lyden, J.T., Mathews, R., Sitzman, K.L., Vanderpuije, A. Mav, D., Kendra, M.A., Klein, C. and Humphrey, C.J. (2008) Blood exposure incidence rates from the North Carolina study of home care and hospice nurses. American Journal of Industrial Medicine. 10.1002/ajim.20646

Abstract:

Background: Home care/hospice nurses may be at elevated risk of blood exposure because of the nature of their work and work environment. However, little is known about the incidence of blood exposure in this population.

Methods: A mail survey (n = 1,473) was conducted among home care/hospice nurses in North Carolina in 2006.

Results: The adjusted response rate was 69%. Nine percent of nurses had at least one exposure/year. Overall incidence was 27.4 (95% confidence interval: 20.2, 34.6)/100,000 visits. Nurses who had worked in home care 5 years had higher exposure rates than other nurses – seven times higher for needlesticks and 3.5 times higher for non-intact skin exposures. Nurses who worked part time/contract had higher exposure rates than nurses who worked full time – seven times higher for needlesticks and 1.5 times higher for non-intact skin exposures. The rates for part-time/contract nurses with 5 years experience were extremely high. Sensitivity analysis showed that it is unlikely that response bias had an important impact on these results.

Conclusions: Approximately 150 North Carolina home care/hospice nurses are exposed to blood annually. If these results are representative of other states, then approximately 12,000 home care/hospice nurses are exposed each year nationwide. Improved prevention efforts are needed to reduce blood exposure in home care/hospice nurses.

American Journal of Industrial Medicine.

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Needlestick injury report

The Royal College of Nursing said simple shielded needles could stop most accidents and protect nurses from infections such as HIV and hepatitis. But the poll of nearly 2,000 nurses in the UK suggests that nearly half do not have access to safer needle devices.

The RCN write “The RCN has called on the Government and employers in the NHS to introduce needle policies and invest in safer alternatives to traditional needles to prevent needlestick injuries occurring. The College’s comments follow the publication of an RCN report which found that nearly half of all nurses (48%) have been injured by a needle that had previously been used on a patient.

The report, entitled Needlestick Injury in 2008 highlighted the danger which nurses faced whilst carrying out their work, despite the fact that the majority of employer had a needlestick policy in place:

• 34% of respondents felt at risk of contracting diseases such as HIV and Hepatitis C following injuries.
• In 90% of cases, the injury drew blood.
• 28% of respondents did not receive any employer advice about the risk of blood-borne diseases after reporting an incident to their employer.
• Only 55% received any form of training from their employer on safer needle use.

Dr Peter Carter, Chief Executive & General Secretary of the Royal College of Nursing said:

“Government and employers in the NHS need to start taking this issue seriously by introducing needle policies and investing in safer alternatives to traditional needles, so that these accidents don’t happen in the first place. Nurses should also receive full support from their employers when they sustain an injury because no one wants to feel isolated and alone when going through such trauma”.

4,407 nurses responded to the RCN Needlestick Injury in 2008 survey published in the RCN’s fortnightly Bulletin magazine and a further 320 nurses completed an online survey. The RCN says it is now looking forward to working with the Government, regulators and employers to address the issue. The report was launched to MPs, peers and stakeholders at the House of Commons yesterday (18 November 2008).

Read the RCN needlestick injury 2008 report.

More on the BBC news channel.

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Needlestick and insulin pens

Kiss, P., De Meester, M. and Braeckman, L. (2008) IV injuries in Nursing Homes: The Prominent Role of Insulin Pens. Infection Control and Hospital Epidemiology.

Abstract:

Causes and circumstances related to 162 needlestick injuries in nursing homes were analyzed. In addition to nurses, geriatrics helpers were found to be an important occupational group at risk. Insulin pens were the most frequent cause of needlestick injuries among nursing personnel. Insulin pens are a major instrument involved with unsafe needle-handling practices.

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Syringes reused during endoscopy

Public health officials in Alberta are looking for 2,700 former patients of a small hospital in the western Canadian province, after staff there reused syringes to administer medication through intravenous lines.

The Alberta government said on Monday that staff at a health complex in High Prairie, a small town about 300 km (186 miles) northwest of the provincial capital of Edmonton, were using syringes to inject medication into plastic intravenous lines of multiple patients.

Click here for the story on Reuters.

Click here for the story on CTV.

Update 29th October 2008 – The nurses who reused syringes in a northern Alberta hospital should bear some responsibility for their actions and possibly face sanctions, says a local nursing professor.

Click here for the full update.

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Needlestick fine

Allcare Dental and Dentures, has agreed to pay $44,550 in fines to the federal Occupational Safety and Health Administration after an employee was accidentally stuck with a used needle. Allcare Dental and Dentures admitted no wrongdoing in settling the allegations of safety violations.

Click here for the full story.

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Seat belt associated central line fracture

Ghayyda, S.N., Roland, D. and Cade, A. (2008) Seat belt associated central line fracture-A previously unreported complication in cystic fibrosis. Journal of cystic fibrosis. 7(5), p.448-9.

Totally implantable venous access devices (TIVAD) are used widely in the management of cystic fibrosis (CF). They have been shown to be safe and advantageous in the long term administration of intravenous antibiotics. However, TIVADs are not without short and long term complications including infections, thrombosis and mechanical failure. Patients should be counselled prior to TIVAD insertion regarding the risks and instructed on post-operative care of the device to minimise the risks. However it is not routine practice to advise on seating position within the car in relationship to the seatbelt placement over the anterior chest wall. Line failure due to direct pressure from a seatbelt worn to prevent injury in the sudden deceleration involved during a motor vehicle accident (MVA) has not been described previously in the CF literature We report the case of an 8 year old child who fractured her Vascuport(R) line secondary to seatbelt trauma following a road traffic accident (RTA). Children and adults with CF should be advised to sit in the car on the side that places the shoulder strap of the seatbelt on the opposite side to the TIVAD line.

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Leaking central line

A UK hospital have apologised to the family of a man who died following ”shortcomings” in the care he received. The 64-year-old, known only as “Mr C,” died of a heart attack at the Western General Hospital in 2006. He had been admitted four days earlier when his condition worsened following bowel surgery. 

After a complaint to the Scottish Public Service Ombudsman, a number of issues were probed at the hospital’s high dependency ward. The ombudsman’s report noted that records had not been properly kept in the run-up to Mr C’s death, making it difficult for nurses to keep track of medication. It also highlighted a leaking insulin tube, which was designed for treating the man’s diabetes but was, in fact, only succeeding in making his gown wet. 

The ombudsman’s report concluded: “The advisers were clear that one could not say whether Mr C’s death was avoidable. For example, one could not say that the issues with the leaking central line led to his death”.

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Patient safety congress 2009

Health Service Journal and the Nursing Times are delighted to announce the launch of the Patient Safety Congress 2009. Following the immense success of the inaugural event last May, which saw 800 delegates and over 100 speakers, we are pleased to bring you early information about next year’s event. We have again teamed up with the National Patient Safety Agency, the NHS Institute for Innovation and Improvement and the Health Foundation, and this year the Department of Heath HCAI and Cleanliness Division and NHS Connecting for Health have also joined our partnership.

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Symposium includes needlestick

The National Institute for Occupational Safety and Health (NIOSH), through the Division of Safety Research, has a broad research program focused on preventing traumatic occupational injuries. As part of this effort, NIOSH is hosting the fourth National Occupational Injury Research Symposium (NOIRS) on October 21–23, 2008, at the Sheraton Station Square in Pittsburgh, Pennsylvania. NOIRS is the only national forum for presenting research methods, data, and findings focused exclusively on the prevention of occupational injuries. Abstracts from the oral and poster session presentations will be posted to the NIOSH website after the symposium.

Leading researchers in occupational injury prevention will present findings about many major categories of injury, including needlestick. Those unable to attend the conference can participate electronically by posting comments, research, and real-world examples on the NIOSH Science Blog.

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Drug calculations for nurses

Nurses’ poor maths is putting patients’ lives at risk, a Government report has revealed. A new study carried out in Lothian hospitals reveals “widespread confusion” in the nursing sector over how to calculate correct dosage of powerful intravenous drugs.

Tutors observed 40 nurses in voluntary remedial numeracy workshops at Edinburgh’s Western General and Royal Infirmary and at St John’s Hospital in Livingston. They found they had difficulty converting doses from larger to smaller units, adapting doses using fractions or multiplication, calculating flow rates, and applying patients’ weight to adjust dosages.

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Peel-off labels reduce drug errors

A study presented at the 2008 Annual Meeting of the American Society of Anesthesiologists proposes that the relatively simple act of universalizing the look of medication labels can significantly decrease the occurrence of medication errors ― errors that cause patients unnecessary harm and cost the health care industry an estimated $3.5 billion each year.

According to Elizabeth H. Sinz, M.D., Donald E. Martin, M.D., and their group from the Department of Anesthesiology at Penn State Hershey, medication errors are all too common.

“An average hospital patient may experience one medication error per day, contributing to 1.5 million preventable adverse drug reactions each year,” said Dr. Sinz.

Around one-third of these events are the result of errors during the process of administration of intravenous medications ― but there currently are no regulations on color usage in the labeling of pharmaceutical products. The Penn State study points to some fairly simple solutions.

“We propose that general use of the international color coding of drug classes used in anesthesia by the pharmaceutical industry for labeling and medication packaging might reduce the number of errors which result from human factors,” said Dr. Martin.

In the study’s simulated operating room environment, volunteer anesthesiologists, residents and nurses drew up medications with different colored labels at an ever-increasing speed to mimic an emergency. The research group then counted mistakes and near-mistakes and found that although the number of actual mistakes was too low to detect a difference, when the color of the label on the syringe matched the color of the label on the bottle, fewer near-mistakes occurred compared to when the colors didn’t match.

And when peel-off labels that are taken off the bottle and placed on the syringe were used, errors were reduced and fewer commands were skipped.

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Needlestick injury in prison

A prisoner who was injured by a syringe hidden in his cell mattress has been awarded damages. Mr Kevin D’Arcy, counsel for Jonathan Coyle, told the Circuit Civil Court his client’s hand was pierced when he accidentally grabbed the needle of a hypodermic syringe while tucking bedding under the mattress. The syringe had been hidden in a tear in the mattress.

Awarding Coyle €7,500 damages, Judge Deery said evidence had revealed the cell had not been locked at all times and that the prison governor’s directions in regard to search procedures had not been fully complied with.

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