Infusion pump recall update

Intravenous conference: ECRI Institute’s® Web Conference, “Replacing your Baxter Colleague Infusion Pump,” on September 22, 2010, from 1 to 2:30 p.m., ET, will provide a roadmap for facilities who are affected by the Read more

Sharps injury warning

Intravenous products: The FDA report “CDC and FDA have noted a progressive increase in the reports of bloodborne infection transmission over the past 10 to 15 years (primarily hepatitis B virus), resulting from the Read more

Huber needle update

Intravenous products: The FDA report “FDA continues its investigation through the inspection of Huber needle manufacturers. Inspections found increases in incidents of coring with Huber needles. The agency is Read more

Neonatal IV safety alert

Intravenous news: The NPSA report “There is a risk of the accidental over infusion of intravenous fluids and medicines to neonates associated with the setting up of specific intravenous infusions or the overriding of Read more

Interventional HepC infection

Intravenous news: jacksonville.com report “Three transplant patients at Mayo Clinic may have contracted hepatitis C from a Mayo employee who was fired Tuesday, the clinic reported Tuesday night. The employee, Read more

Contaminated intravenous feed

Intravenous news: dw-world.de report “A third baby has died after receiving a contaminated intravenous drip at a hospital in Germany. A spokeswoman for Mainz University Hospital said that the premature Read more

Syringe reuse error

Intravenous news: Wisconsin State Journal report “The state Department of Health Services cited the University of Wisconsin Hospital for four deficiencies after a syringe was reused on a second person, Read more

IV misconnection research

Intravenous news: nytimes.com report “Thirty-five weeks pregnant, Robin Rodgers was vomiting and losing weight, so her doctor hospitalized her and ordered that she be fed through a tube until the birth of her Read more

Opioid tolerance – delayed pump refill

Intravenous literature: Ruan, X., Couch, J.P., Liu, H., Shah, R.V., Wang, F. and Chiravuri, S. (2010) Respiratory Read more

Intravenous Paracetamol alert

Intravenous news: The MHRA report “Cases of accidental overdose have been reported during treatment with Read more

Safer administration of insulin

Intravenous news: The NPSA have issued resources related to the safer administration of insulin. The NPSA Read more

NICU medication errors

Intravenous literature: Stavroudis, T.A., Shore, A.D., Morlock, L., Hicks, R.W., Bundy, D. and Miller, M.R. (2010) NICU Read more

IV potassium error death

Intravenous news: dailymail.co.uk report “A grandmother being treated in hospital for a mild case of pneumonia died after Read more

Heparin lawsuit continues

Intravenous news: SCPR.org report “A representative for a health care provider today responded to a lawsuit by Dennis Read more

Safer injections

Intravenous news: The Safe Injection Practices Coalition (SIPC) is launching a new educational video for U.S. Read more

PICC advice

Intravenous alert: Recent MHRA one liner offers some short advice on PICC safety. The MHRA state “Intravenous Read more

IV errors investigated

Intravenous products: NursingTimes.net report “Senior nurses could form special investigation teams which would be Read more

£100,000 fine following IV error

Intravenous news: TimesOnline.co.uk report “A hospital trust that was fined £100,000 yesterday after Read more

Blood glucose lancet re-use error

Intravenous news: Associated Press report: “A group of New Mexico medical school students failed to properly Read more

Call to destroy infusion pumps

Intravenous news: The U.S. Food and Drug Administration sent a letter to Baxter Healthcare Corp. on April 30 Read more

Needlestick injury investment

Intravenous news: News-Medical.net report “According to the Australian Nurses Federation (ANF) there are Read more

Central line cardiac tamponade

Intravenous news: Leagle.com report “Shortly after Jamia Hoard was born at Roper Hospital in Charleston, Read more

Alaris GP IV pump alert

Intravenous products: The MHRA report “Due to a software irregularity, if the previous set up is not cleared at Read more

IV drip rate App

Intravenous products: Designers in Wales have come up with a novel idea to help staff calculate and set gravity Read more

Infusion pump improvement

Intravenous news: FDA report “External infusion pumps are medical devices that deliver fluids, including Read more

Nurse probably contaminated saline flush

Intravenous news: TampaBay.com report “A hepatitis C outbreak at a holistic medical clinic in Brandon was likely Read more

Cardiac surgery without transfusion

Intravenous literature: El Azab, S.R., Vrakking, R., Verhage, G. and Rosseel, P.M.J. (2010) Safety of cardiac Read more

IV drug administration safety

Intravenous literature: Webster, C.S., Larsson, L., Frampton, C.M., Weller, J., McKenzie, A. Cumin, D. and Read more

Sharps injury danger

Intravenous news: NursingTimes.net report “Nurses will remain at risk of unnecessary sharps injuries Read more

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.

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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.

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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).

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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.

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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.

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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.

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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. 

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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.”

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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.”

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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.

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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.”

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