Failure to monitor fluid balance

NHS Tayside has agreed to apologise to the family of a 79-year-old man who died in Ninewells Hospital Read more

Heparin update New Zealand

Stewart Jessamine, Group Manager, Medsafe in conjunction with the Ministry of Health (NZ)  are continuing to monitor the situation with respect to the global problem of heparin contaminated with over-sulphated chondroitin sulphate (OSCS) entering the market.

Medicines regulators around the world have taken a number of different approaches to managing this issue.  In New Zealand, Medsafe requires all manufacturers of heparin-based products to test for the presence of OSCS in products supplied to the market. To date all of the manufacturers of heparin and low molecular weight heparin products supplied to New Zealand have reported that OSCS has not been detected in the products used by patients.

Click here for the full update.

Barcode medication system

Actor Dennis Quaid, whose twins were given an overdose of a blood thinner as newborns at a California hospital, toured a Dallas hospital on Tuesday to learn about a system to prevent such errors.

Officials at Children’s Medical Center Dallas showed Quaid and his wife, Kimberly, the hospital’s system of bar-coding medications to allow the drugs to be tracked electronically from the point of dispensing until being administered to the patient.

“This system here at Children’s Medical Center, I’m really amazed … it’s beyond cutting edge,” Quaid said at a news conference after the tour.

Click here to view the full story.

 

Medical Device Alert MDA/2008/051

The MHRA have issued  a medical device alert (MDA/2008/051) which concerns the Kimal safety fistula needle. Kimal is aware of the potential for the unintentional retraction of the cannula into the protection sheath, which can result in exsanguination.  As a result, Kimal is recalling all lots of the device. 

 Click here to view the alert. 

 

Epidural and IV confusion

In 2006 Jasmine Gant, 16, died following a mistake by nurse Julie Thao. Jasmine died following an inadvertent disconnection of her epidural during childbirth. Thao mistakenly attached the epidural to the IV device.

The Wisconsin State Journal state that progress has been made to increase the safety associated with tubing connections, but obstacles continue.

“It’s inching along,” said Rod Hicks, a professor at Texas Tech University and former research manager at U.S. Pharmacopeia, a nonprofit organization that sets standards for the drug industry. “But these errors can still occur. We have not made the world a safer place yet.”

This article calls for industry to provide the solution to safer tubing connections in healthcare.

Click here to read the full story.

Revised EU monographs for heparin

The MHRA have reported a revision of European Pharmacopoeia monographs for heparin.

“Following increased reports of adverse events associated with heparin preparations in the United States of America and some European countries, the European Pharmacopoeia monographs for Heparin Calcium (0332) and Heparin Sodium (0333) have undergone rapid revision and implementation in order to strengthen the level of testing required for quality control.

The revised monographs were adopted by the European Pharmacopoeia Commission on 25 June 2008 and are expected to come into effect on 1 August 2008, pending a decision by the European Committee on Pharmaceuticals and Pharmaceutical Care (CD-P-PH).

The revised monographs will be published in European Pharmacopoeia Supplement 6.4 and supersede the relevant monographs published in the British Pharmacopoeia 2008 and 2009 editions.

Further information and copies of the monographs can be obtained from the EDQM (European Directorate for Quality of Medicines & HealthCare) website“.

Cannula insertion documentation

Our recent IVTEAM poll has just finished. We asked the question “Should you record lot/batch numbers following cannula insertion”? 87% of IVTEAM visitors felt that it was important to record lot/batch numbers. Thank you to all who voted.

Our new poll has just been launched. IVTEAM are now asking “When securing a peripheral cannula do you use strips for additional fixation”?

Please visit our poll at the bottom of the page and cast your vote now.

Wristband warnings

IVTEAM have reported before on the use of wristbands in healthcare (click here). Well, its back in the press and yes we still have a problem with the ‘Do Not Resuscitate’ wristband!

BroMenn Healthcare and St. Joseph announced Monday that the two health care organizations have collaborated on color-coded wristbands to immediately alert doctors and hospital staff to critical information about patients. Eureka Community is part of BroMenn Healthcare.

“It’s an exterior red flag to (staff) that there’s something to be aware of,” explained Mary Anne Kirchner, a registered nurse and BroMenn clinical education specialist.

A red band indicates a patient allergy, yellow identifies a patient at risk of falling, purple is a sign that the patient has a do-not-resuscitate order on file, and pink is for patients with an arm or leg that shouldn’t be used for procedures such as blood pressure checks, intravenous infusions and blood draws.

Click here for the full story.

Vascular access in court

Four condemned prisoners are attempting to stop executions in Mississippi. They say the state’s method of lethal injection is unconstitutional because it might cause pain.

The inmates have issues with numerous parts of the process. One particular issue that they highlight is that they believe the insertion of the intravenous needle could also be a painful because the execution staff in Mississippi are not properly trained.

State officials dismiss the allegations, saying in court papers that the staff “is a highly trained team of paramedics” and that a state pathologist is on hand.

Click here for the full story.

Extravasation injury baby

Baby Lai Yok Shan, who lost her left arm soon after birth when it turned gangrenous, turned one year old on Read more

Baby died following extravasation

A coroner has ruled doctors at a Plymouth hospital were not to blame for the death of a two-week-old premature baby who died after the contents of her feeding tube leaked.

A paediatric expert at the inquest, Professor Peter Fleming, agreed with the doctors who treated Brooke, that the feeding fluid had led to a chemical erosion of the blood vessel it was in, causing it to leak into her liver and abdomen.

The coroner’s narrative verdict acknowledged the leakage contributed to Brooke’s death, but said her feeding tube had been inserted correctly by doctors.

The photograph shows Brooke Herridge who was born prematurely at 27 weeks.

Click here for the full story.

 

Fatal intrathecal drug error

The Times of India reports that a 37-year-old engineer died on Wednesday morning, allegedly because of Read more

Central catheter infection rates

New York city and New York state hospitals report catheter related blood stream infection rates.

In New York City, 2.8 out of 1,000 central lines at medical intensive care units resulted in infections, compared to 3.6 upstate. In the city, another 2.7 out of 1,000 central lines in surgical ICUs resulted in infections, compared to 4.8 in upstate facilities.

Officials credited a collaborative among 60 hospitals in the New York metropolitan area aimed at reducing hospital-acquired infections. According to the most recent data provided by the collaborative, which was established in 2005 by the United Hospital Fund and the Greater New York Hospital Association, the rate of central line infections was 2.33 infections for each 1,000 central line days as of December 2007, down from 4.98 infections for each 1,000 central line days in June 2005.

Click here for the full story.

Another story click here.

High tech clean rooms

Hamad Medical Corporation has established the first pharmacy manufacturing  clean rooms in the Middle East. The clean rooms are being established in a bid to improve pharmaceutical activities within the corporation. Fully automated chemotheraphy machines have been installed in these rooms, which ensure sterile products, reduce human error and infections to patients.

Opening three such rooms yesterday at the hospital’s pharmacy department were Mohamed al-Nama, assistant executive director; Abdul-Rasak al-Kubaisi, assitant managing director Operations; Manal Borhan al-Zaidan, Al-Amal Cancer Centre director of Pharmacy; as well as corporation’s director of Marketing and Public Relations Mohamed al-Noaimi.

Al-Zaidan said that the decisions by the corporation to set up the additional clean rooms were to reiterate its commitment to excellence in patient care.

“These clean rooms are first of its kind in the Middle East and it is also very rare to find in the world as well with its high standard installations,” she said.

Click here to view the full story.

Click here for another story.

Heparin overdose

A Corpus Christi hospital says 14 babies in its neonatal intensive care unit received overdoses of the Heparin. 

Christus Spohn Hospital South CEO Bruce Holstein says the error in the dosage of the medicine - used to flush intravenous lines to prevent blood clots from forming - was discovered Sunday night by hospital nurses. He says the nurses noticed abnormalities in lab tests. 

Pharmacy operations were halted temporarily Monday. He said the error was believed to have happened in the pharmacy when the medicine was mixed.

Click the following links for the full story - Fox News - KRISTV - CBS News

UPDATE: The error was unrelated to product labeling or packaging of pediatric heparin, according to the statement by Dr. Richard Davis, chief medical officer of Christus Spohn Health System. 

IVTEAM beat nursing shortage

Dan Ast is a member of the IV therapy team at Via Christi Regional Medical Center-St. Joseph Campus.

As the nursing shortage worsens, Via Christi has adopted new ideas to make up for vacancies, things like the specialization of nurse tasks like those carried out by Ast and his team.

His bosses say these ideas have saved nurse time and improved care in spite of the shortage.

“It’s pretty simple how we can help,” Ast said, leaning back in his chair in his blue scrubs. “We’re nothing special compared with any other nurses, but we specialize in placing IVs, so we get really good at it. It’s not easy to place an IV, so a nurse on rounds might take 30 minutes to find and gather all the materials, then find the vein, then place it.

“I can do it all in 10 minutes or less.”

Saad Ehtisham, the senior vice president and chief nursing officer for Via Christi Wichita Health Network, said the IV team and other specialist teams created at Via Christi have become invaluable at a time when the vacancies have left hospitals 8.8 percent short of the registered nurses they need.

Click here for the full story.

FDA update on heparin

The FDA have recently released a video update on the contaminated heparin issue.

Over the past several months, FDA has been alerting healthcare professionals and the public about medical products that may contain contaminated heparin, which has been associated with a number of serious adverse events. Here is an update and recommendations on this continuing issue.

If the video does not show click here.

FDA update page here.

 

Pharmacy admix training

Trinity Regional Health System are to offer training programs for pharmacy technicians, those who prepare medications and assist licensed pharmacists. Previously, pharmacy technicians have been required to have only a high school education and a clean criminal record. New state laws in both Iowa and Illinois will ensure they require certification.

“This program is all about medication and patient safety when they come into the hospital. More education for staff means increased leadership and quality of standards,” said Amy Descamps, Trinity’s lead pharmacy technician, who will also be the training program’s lead instructor.

A 2006 case involving Emily Jerry, a 2-year-old cancer patient in Ohio, seems to have triggered a nationwide change in laws regarding pharmacy technicians. The girl’s abdominal tumor, which was the size of a grapefruit, had responded to treatment and shrunk. During her last round of chemotherapy, though, a pharmacy technician formulated her medicine at 26 times the level it should have been. The error went unnoticed and the girl died three days later.

Click here for the full story.

UK IVTEAM win award

A new IV team were the overall winners at the Calderdale and Huddersfield NHS Foundation Trust’s annual awards for staff innovation and excellence. Sian Bloomfield, Bev Waller and Bernie Coll are the “IV Team”.

This team tours Huddersfield Royal Infirmary and the Calderdale Royal Hospital, advising staff on the best ways of inserting tubes into patients as a way of reducing the risk of infection.

The Team won the £5,000 Gordon McLean Award, to be re-invested in the project.

Bev said: “We are shocked but very pleased; but this is not just our success.” Sian said: “This is the success of staff on the wards as they are the ones making the changes.”

The team has created new documentation, standardised equipment and set up a special IV trolley. It is so good the Government’s Health Department wants to widen its use among other hospital trusts.

I would also like to congratulate them… well done to you all… keep up the good work.

Click here for the full story.

Environmental IV

I am very pleased to see that environmental questions are being asked of intravenous therapy.

Missoula’s two hospitals are moving toward sustainability and green practices as they examine the environmental health of the workplace.

Across the country, reducing waste, eliminating mercury and improving environmental stewardship is a trend evolving in the health care industry.

St. Patrick Hospital and Health Sciences Center was one of 141 hospitals, health systems and health care organizations recently awarded for its efforts by the nonprofit Practice Greenhealth.

Across town, Community Medical Center’s environmental awareness work group will hold its first meeting Friday to pursue green practices.

The hospital is also working to eliminate mercury in lab reagents and PVC plastics in intravenous tubing.

Click here for the full story.

 

Patient experience video

AstraZeneca have launched a website that allows anyone to upload a video of their experience with needles. It only contains a few videos at the moment. But over time I can see how health professions may benefit from patient experience posted on the Internet.

Thank you to Jon Moss for highlighting this site - you can check out his review of the ihateneedles site here or you can go straight to the videos at the ihateneedles site by clicking here.

Wireless may disrupt IV devices

It have recently been reported that Wireless systems used by many hospitals to keep track of medical equipment can cause potentially deadly breakdowns in lifesaving devices such as electronic infusion devices.

Some of the microchip-based “smart” systems are touted as improving patient safety, but a Dutch study of equipment — without the patients — suggests the systems could actually cause harm.

The wireless systems send out radio waves that can interfere with equipment such as respirators, external pacemakers and kidney dialysis machines, according to the study.

Researchers discovered the problem in 123 tests they performed in an intensive-care unit at an Amsterdam hospital. Patients were not using the equipment at the time. Nearly 20 percent of the cases involved hazardous malfunctions that would probably harm patients. These included breathing machines that switched off; mechanical syringe pumps that stopped delivering medication; and external pacemakers, which regulate the heart, that malfunctioned.

Click here to read the full story.

Click here for the story again - different report.

UPDATE - Another news item - Wireless Hospital Tracking System Study Needlessly Alarms Public.

Barcode patient

The nurse scans the wristband barcode to make sure it matched information on his medication and on her computer screen.

Wayne Memorial’s new Bedside Medication Verification (BMV) program officially launched this month. BMV supports the “Five Rights” of Medication Management: Right Patient, Right Medication, Right Dosage, Right Route, and Right Time. Caregivers scan the patient’s wristband barcode and then scan the code on the medication to be administered to correctly identify that the right medication at the right dose is being given to the right patient at the right time and by the right route (intravenous, oral, etc). 

 “This is a real milestone for Wayne Memorial,” said David Hoff, Chief Executive Officer. “BMV is one of the most important steps we’ve ever taken for patient safety.”    

Click here for more on this story

 

ASHP House of Delegates

The House of Delegates of the American Society of Health-System Pharmacists (ASHP) considered a number of professional issues during its 60th annual session in Seattle. One such issue was…

“Standardization of Intravenous Drug Concentrations: To develop nationally standardized drug concentrations and dosing units for commonly used high-risk drugs that are given as continuous infusions; further, to encourage all hospitals and health systems to use infusion devices that interface with their information systems and include standardized drug libraries with dosing limits, clinical advisories, and other patient-safety-enhancing capabilities”.

Click here for more on this story.

 

Nursery ICU CRBSI free

UCSF’s William H. Tooley Intensive Care Nursery has gone 135 days without a single central line-associated bloodstream infection.

“The reduction in infection is really due to a change in culture at UCSF,” says Michelle Cathcart, RN. “Dr. Yao Sun has been instrumental in creating the cultural shift which supports nurses in their role as gatekeepers.”

In addition to hand hygiene, nurses at UCSF also enforce no wearing of jewelry or long-sleeve shirts in the NICU. These rules apply to anyone touching a baby, including nurses, physicians and family members. UCSF best practices also include the use of chlorhexidine, an antimicrobial agent for cleaning skin, and training a core group of nurses to do dressing changes for central lines.

Click here for the full story.
 

IV history

Neil MacGillivray writes in the Herald about Dr Thomas Latta who was one of the forefathers of infusion therapy. Asking “if it is time for Edinburgh to honour the memory of a remarkable pioneer whose work has been largely forgotten”. 

“Dr Thomas Latta of Leith, who, during a cholera epidemic in 1832, treated cholera for the first time by the intravenous injection of saline, reporting his findings in a letter to the Lancet in May 1832, has been forgotten. His use of intravenous saline was for the time a remarkable attempt to correct the catastrophic loss of body fluids which is the main cause of death in cholera. Many decades were to pass before fluid replacement became recognised as the standard treatment that is in use today ” (MacGillivray 2008).

MacGillivray continues “A colleague of Latta’s in the Edinburgh Cholera Hospital in Drummond Street, Dr John Mackintosh, wrote after Latta’s death in 1833″: “Although Dr Latta’s exertions and fate must have been known to a number of influential men, his grave does not exhibit any monument of public gratitude.”

If you want to read more about Thamas Latta you will find an excellent article by Neil MacGillivray here.

 

Vascular Access Team

Specialist nurses are working across the Royal Devon & Exeter NHS Foundation Trust to develop and improve Intravenous Access – one of many initiatives expected to collectively contribute to a reduction in healthcare associated infections.

Over the next year the Vascular Access Team will be assessing current IV access practice at the RD&E hospital, developing practice to ensure patients are assessed and given the appropriate IV device for their healthcare needs; carrying out audit work to ensure lines are appropriately managed and the risk of infection reduced; and taking an active role in educating medical and nursing staff about the insertion, care and removal of IV devices.

Pictured from right to left: Senior Vascular Access Nurse Specialist Vicki Shawyer with Vascular Nurse Specialists Helen Williamson and Barbara Hector.

Blood transfusion opposition

A judge has ruled that the rights of the Jehovah’s Witness parents of sextuplets born in Vancouver were not violated when doctors administered blood transfusions to the premature babies.

During the treatment of four premature babies transfusions were given against the wishes of the parents, who are members of a religion that opposes such medical procedures. After the transfusions, the babies were returned to their parents and since then their development has progressed well without any significant health problems.

In making his ruling, B.C. Supreme Court Chief Justice Donald Brenner noted that the babies were born Jan. 7, 2007 at the B.C. Women’s and Children’s Hospital at 25 weeks and had extremely low birth weights, requiring resuscitation. They were admitted to an intensive care unit where they received life support including ventilation, oxygen, intravenous nutrition, the drug erythropoietin and other medications. Two babies died due to complications. During the treatment of the other four, physicians deemed that blood transfusions were a medical necessity.

Click here to read the full story.

Medical litter

In this fascinating article JoNel Aleccia reports on the phenomena of medical litter; fragments of medical devices that are left inside patients.

Since 2003, reports of 72 deaths and 4,675 injuries associated with “unretrieved device fragments,” or UDFs, have been logged in the FDA database that tracks adverse events.

The most common problem occurs when wire guides for catheters used in heart operations break or fracture, leaving the device or fragments behind.

Click here to review the full story.

 

Virtual reality IV insertion

UK Haptics have recently announced that the NHS National Technology Adoption Hub will use the Virtual Reality Clinical Skills Training Systems as one of four new Technology Implementation Projects.

The Virtual Reality Clinical Skills Training System delivers virtual reality, combined with the latest haptics technologies that introduce a sense of touch to human and computer interaction and realistic 3D graphics.

The NHS National Technology Adoption Hub aims to help technology companies overcome the barriers to the NHS adopting innovative new technology products. Their primary aims are to:

• Increase the uptake of new technology in all areas of the NHS.
• Work with partners to identify excellent technologies which will improve healthcare in the NHS.
• Promote greater cooperation between all organisations involved in the development and use of healthcare technologies in the NHS.

Click here for further information from UK Haptics

Click here for further information from the NHS National Technology Adaption Hub

 

Intravenous drip patient dies

A clinic where patients died or fell ill after receiving intravenous drips had sloppy hygiene control, such as sharing the same hand towels among nurses, it has emerged.

Tanimoto Orthopedic Clinic in Iga, Mie Prefecture, is accused of keeping mixed intravenous drip solutions for a period of time before administering them to patients.

One of the patients, a 73-year-old woman, died after receiving an intravenous drip at the clinic, while several other patients fell ill.

“We used to keep mixed intravenous drip solutions for a while,” said Hiromichi Tanimoto, head of the hospital, as he met reporters in front of the clinic on Thursday.

Click here to read the full story.

Intravenous connection error

A settlement has been reached between an Idaho Falls hospital and the family of a 73-year-old woman who had sued the hospital over her death on May 21, 2003.

She was taken to the hospital May 12 after collapsing at her home. Doctors at the hospital determined a brain hemorrhage. The patient had a catheter placed in her head to drain excess fluid from her brain.

On May 14, a nurse found that the patient had decreased consciousness and discovered that medications that should have been injected through an intravenous line were instead connected to the tube that drained fluid from her brain. Her health then declined to where she had to be connected to a ventilator. She died a week later.

Click here to read the full story.

Intravenous Nurse vacancy

An exciting opportunity has arisen for a motivated and highly enthusiastic individual to become part of the dynamic and innovative IV Team.

The post will be based at the Royal Sussex County Hospital and will involve working at the Princess Royal Hospital in Haywards Heath for 2 days per week. The IV Therapy Nurse will work alongside the Clinical Nurse Specialist and Clinical Practice Development Nurse to ensure continued development of the Intravenous therapy service across the Trust. The post holder will provide training and support to all staff within the Trust. They will be a vital part of the Midline and PICC insertion service.

The ideal candidate will have experience of working within an acute setting, for example ITU or Recovery and possess IV therapy skills including venepuncture and cannulation. Experience of PICC placement would be an advantage, although full training can be given.

Click here for further information.

Japanese IV Clinic

First of all oxygen bars, then ice bars! Now we have IV clinics offering intravenous drips to stressed and exhausted workers.

A Tokyo clinic treats up to 50 run down businessmen a day. The intravenous drip costs as little as 2000 yen ($20). The cheapest option, a 10-minute drip contains saline solution and vitamins B6, B12 and C.

Jun Kodama, a rundown 37-year-old banker who visited the Tenteki10 clinic recently to treat a hangover with a 10-minute Green Pack, admitted that “it’s probably not sensible or healthy to rely on this sort of treatment too much”. Added Mr Kodama: “I think occasionally it’s OK if I really need to be working efficiently in my job.”

Click here to view the full article.

 

Heparin flushes

The use of heparin has suddenly come under the spotlight in the UK. However, the reason for this attention is different to previous concerns in countries such as the US.

“An independent report has recently been published reviewing the circumstances of four patient safety incidents where an anaesthetist mis-selected sodium heparin 25,000 units in 5 ml (Monoparin) instead of sodium heparin 50 units in 5 ml (Hepsal) and administered the more concentrated solution in unlabelled syringes to four children. Thankfully the four children only experienced some temporary bleeding and otherwise are not reported to have suffered longer term harm. However, the potential for serious harm was recognised by the hospital trust” (NPSA 2008).

The NPSA state:

• Organisations should review local policies to minimise the use of heparin flush solutions in all devices, including complex central venous or arterial catheters.  This should take into account the evidence reviewed by UK Medicines Information (UKMi) which confirms that heparin flushes should not normally be used to flush peripheral intravenous catheters.  
• All flush solutions should only be administered following a prescription or patient group direction.
• Local policy and procedures should be reviewed to ensure risk with heparin flush solutions is minimised.
• Healthcare organisations should ensure that all relevant staff are made aware of this guidance and revised policy.

The Rapid Response Report from the NPSA can be viewed here and further support information can be viewed here.

Vacancy - IV Therapy Practitioner

I have just read that Royal Manchester Children’s Hospital is advertising for a Band 6 (22.5 hours) IV Therapy Practitioner.

“Our team comprises of dedicated paediatric nurses working collaboratively within a friendly, dynamic department to deliver family-centered care that meets the individual needs of every child. And you will take their skills to the next level alongside RSCN or RN Child qualifications, you should bring a proven track record at Band 5 level and demonstrable ability to deliver teaching programmes to staff groups and families”.

For an informal chat please contact Anne Stanton, Tel: 0161 918 5525 or anne.stanton@cmmc.nhs.uk

HepC contamination - CDC full report

The Morbitity and Mortality Weekly Report (MMWR) from the CDC into “Acute Hepatitis C Virus Infections Attributed to Unsafe Injection Practices at an Endoscopy Clinic, Nevada, 2007″ has been published. The report is very thorough, it describes the investigation and highlights how the contamination may have occurred. Click here for the full report.

The CDC write “On January 2, 2008, the Nevada State Health Division (NSHD) contacted CDC concerning surveillance reports received by the Southern Nevada Health District (SNHD) regarding two persons recently diagnosed with acute hepatitis C. A third person with acute hepatitis C was reported the following day. This raised concerns about an outbreak because SNHD typically confirms four or fewer cases of acute hepatitis C per year. Initial inquiries found that all three persons with acute hepatitis C underwent procedures at the same endoscopy clinic (clinic A) within 35–90 days of illness onset. A joint investigation by SNHD, NSHD, and CDC was initiated on January 9, 2008. The epidemiologic and laboratory investigation revealed that hepatitis C virus (HCV) transmission likely resulted from reuse of syringes on individual patients and use of single-use medication vials on multiple patients at the clinic. Health officials advised clinic A to stop unsafe injection practices immediately, and approximately 40,000 patients of the clinic were notified about their potential risk for exposure to HCV and other bloodborne pathogens. This report focuses on the six cases of acute hepatitis C identified during the initial investigation, which is ongoing; additional cases of acute hepatitis C associated with exposures at clinic A might be identified. Comprehensive measures involving viral hepatitis surveillance, health-care provider education, public awareness, professional oversight, licensing, and improvements in medical devices can help detect and prevent transmission of HCV and other bloodborne pathogens in health-care settings”.

Click here for the full report.

Photosensitivity with Cipro

Medscape has recently reported that “The US Food and Drug Administration (FDA) has approved safety labeling revisions to advise of the risks for photosensitivity and phototoxicity in patients receiving treatment with quinolone antibiotics such as ciprofloxacin, updated information regarding the risk for cardiomyopathy in patients receiving trastuzumab therapy, and the potential for developing Clostridium difficile–associated diarrhea more than 2 months after completion of antimicrobial therapy”.

CME credits are available for this subject through the Medscape website.

CDC report on hepatitis cases

The New York times reports that “Health care workers at a Las Vegas endoscopy clinic linked to more than 80 cases of hepatitis C routinely mishandled injection equipment and medication vials and often failed to perform basic hand hygiene, according to a report from the Centers for Disease Control and Prevention released Friday”.

The article also explains the cause of the contamination “Officials noted that IV stoppers were sometimes not properly wiped, that syringes and vials were reused and disinfectant cleaning baths for equipment were used for two endoscopic procedures rather than one as recommended. Health officials believe the hepatitis was spread by the clinic’s reuse of anesthesia syringes among patients”.

Umbilical cord blood

Collection of cord blood at birth will be regulated for the first time in the UK under new rules announced by the Human Tissue Authority (HTA) to ensure safety and traceability.

The trend of collecting cord blood in public or private banks for potential medical applications, including the treatment of leukaemia, has grown more popular in recent years. The new rules, announced today, will mean that from 5 July 2008 cord blood can only be collected by people with specialist training and on premises that meet essential standards.

All maternity units that collect cord blood will need to act under a Human Tissue Authority (HTA) licence that will ensure:

• Staff have training in collecting cord blood, raising standards and making sure that best possible quality of sample is taken.
• Procedures which will help prevent any medical attention being drawn away from mother or child during collection.
• A system is in place to make sure that the cord blood cells are traceable from collection to their use in treatments.

Award for training simulator

Dr David Kessel and team from Leeds, UK have come second in its category at the NHS National Technology awards in London. “The simulator uses virtual reality technology to train people in the skill of ultrasound-guided needle insertion”. Click here for the full story.

Infection control survey

The RCN are seeking views on infection control. The RCN are developing a robust strategy for infection prevention and control. When you complete the online survey remember to add www.ivteam.com to your response for question 17

Click here to complete the online survey from the RCN.

Prescription only cannulae

It has been reported by an NHS hospital that enforcing stricter requests for cannulation has dramatically reduced the incidence of MRSA bacteraemias. The Winchester and Eastleigh Healthcare NHS Trust have started to have cannula insertions ‘prescribed’, in addition they ensure cannula sites are checked at least daily using a scorecard system.

“Winchester and Eastleigh Healthcare NHS Trust has reduced its rates of MRSA bacteraemia infection to zero after introducing a simple prescription technique which could have dramatic effects on infection rates if introduced across the NHS” statement from Louise Halfpenny. Click here for the full story.

COSMOS study launched

The Hospital San Carlos, Madrid, Spain has started to recruit patients into a randomized study of closed peripheral intravenous systems versus open systems. The research team have named it the COSMOS Study (great name… lets hope the results are out of this world).

The purpose of this study is to investigate, in a prospective and randomized fashion, the clinical performance of a closed intravenous system (Nexiva®) versus an open conventional one (Vasocan®), with respect to ease of handling and effectiveness (as defined by time of survival without complications), security provided to professionals and patients against accidental blood exposure or needlestick injury, catheter-related complications such as phlebitis, pain and blockage and overall costs of the two systems.

Primary Outcome Measures:

Length of time catheter remains in place without clinical symptoms.

Secondary Outcome Measures:

Incidence of complications of the catheter, bacterial colonization of catheter tips and costs of therapy.

The study is due to complete July 2008. Click here for further information.

IV Nurse Specialist

Basingstoke and North Hampshire NHS Foundation Trust are advertising for ‘Clinical Nurse Specialist in Intravenous Therapy’. The advert states… “Tasked with the reduction of infections caused by vascular access devices (VAD) you’ll be involved in developing, implementing and monitoring standards of clinical practice in intravenous therapy”.

Further information can be obtained from Zena Ludick, Head of Nursing, Elective Division on 01256 473202 ext 3536.

The job reference is P1178.

You can apply online at www.jobs.nhs.uk or visit www.northhampshire.nhs.uk

Amiodarone and DEHP

The team at Cardinal Health have just informed us that users of Amiodarone should consider administering Amiodarone through a specific aministration set. As Amiodarone may cause the plasticizers to leach into the fluid path.

Medicines.org.uk state that “The use of administration equipment or devices containing plasticizers such as DEHP (di-2-ethylhexyphthalate) in the presence of amiodarone may result in leaching out of DEHP. In order to minimise patient exposure to DEHP, the final amiodarone dilution for infusion should preferably be administered through non DEHP-containing sets.”

Heparin concerns grow in China

The Los Angeles Times has reported that the FDA has asked Chinese manufacturers of products that may contain heparin to test their supplies. This action follows reports of two serious allergic reactions following the use of devices that contain heparin. The FDA will write to 82 medical device manufacturers urging them to test their heparin.

 

Cannulation in Africa

Dr Ngatia writes about task-shifting of health workers on the African continent. He describes how midwives have inserted cannula in the past even though it is illegal for them to do so. However, in Mozambique and Malawi midwives are now trained to set up intravenous drips. Click here to read the full story.

IV contributes to infection

An inquest in Belfast took four hours to find that 43 year old Brendan McDowell died of multiple organ failure brought on by a  ’hospital acquired infection’. This included an infection at his intravenous line which was being used to administer antibiotics. Click here to view the full story. 

Dennis Quaid speaks out about drug error

The actor Dennis Quaid speaks out about the drug error that nearly killed his twins. In the Quaid family case, heparin was mistakenly administered  rather than the IV flush solution ‘heplock’. Follow this link to view Dennis Quaid being interviewed.

$850,000 settlement following drug error

A number of medical errors lead to the the dearth of a three year old at a Florida hospital. Following the $850,000 settlement the hospital has also developed and infusion center in an attempt to improve IV Read more

Driving whilst under the influence

Well it had to happen… a report today has described how a man in china who was tired of waiting for medical treatment hung his IV bag from the rear-view mirror of his car and attempted to drive home… Read more

European needlestick legislation on the cards

The European Union is consulting on legislation to ensure healthcare workers have more safeguards against the potential for needlestick injuries. It is suggested that the proposed legislation will include  Read more

Nurse killer

Colin Norris was today told that he would serve a minimum of thirty years in jail after being found guilty of killing four patients in his care. Other cases include that of serial killers Harold  Read more

Poor injection technique may have infected 40,000 with virus

It has been reported today that thousands of patients may have been exposed to the HIV and Hep B virus during poor Read more

Warning bracelets for allergies

As usual we are searching the net for IV news. Today we came across this little item about patient safety and the use of bracelets. They use red bracelets for allergies, yellow if you are at risk of falls and wait for it… Read more

Syringe vending machines are launched

In an attempt to stop needle sharing  Taiwanese intravenous drug users will be able to use vending machines that dispenses two syringes, diluent and an alcohol swab. Click here to view the full story.

UK nurse died following needlestick

A sad and thankfully rare incident. This nurse received a needlestick injury and developed HIV after testing the blood sugar levels of a HIV positive patient “The hospital room Read more

Martin Kiernan on blood cultures

Another gem of common sense from Martin Kiernan. Martin describes the recent news story that has recently broke with regard to taking less blood cultures.  Read more

Baxter receives clearance from FDA for ’silver’ needlefree

Baxter receive clearance from the FDA for a silver coated needlefree device. The V-Link luer activated device is coated on the outside and the inside with Vitalsheild silver protective coating. This is said to be the first in a series of new products from Baxter. To view this news item in full click here.

Community IV’s in the news

The BBC reported today that an independent group are advising that all trusts look at community IV treatment as an alternative to lengthy hospital stays. Rather than investing in the report they should have just asked :-) Click here to view the news item. 

Nurse fails to wash hands is struck off register

Thank you to Martin Kiernan for highlighting this story in his infection prevention blog. This nurse was struck off by the NMC on six counts of misconduct, which included failing to wear an apron, remove gloves or wash her hands. Hand washing is such a key element of IV care it  Read more

Laughter is the new tourniquet

Arun’s blog hints at the idea that laughter dilates blood vessels. Great, another excuse to try and have fun at work

IV errors

I cannot over emphasise the importance of the BBC news health website. This resource allows us to access a wealth of information. In certain circumstances this information can be viewed as case studies. For example if you search for “nurse” “error” on the BBC news health website you can  Read more

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