BLT Intravenous Therapy Education

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It is estimated that around 25 million patients per year in the NHS have some form of Intravenous (IV) access during their hospitalisation. (1) The increasing number of vascular access sevices has implications for how we practice. (2) According to the RCN, nurses and midwives undertaking the administration of infusion therapy and management of intravascular devices should have undergone theoretical and practical training in the following aspects:

• Anatomy and physiology.
• Fluid balance and blood administration.
• Mathematical calculations.
• Pharmacology and pharmaceutics related to reconstitution and administration.
• Local and systemic complications.
• Infection Control issues (Controls Assurance Standard, 2003).
• Use of equipment including infusion equipment.
• Drug administration.
• Risk management/health and safety.
• Care and management of vascular access devices.
• Infusion therapy in specialist areas covered separately (paediatrics, oncology, parenteral nutrition, transfusion therapy) (3)
• Legal and professional issues

It should be noted that nurses and midwives must be knowledgeable and skilled for the role of IV drug administration and accept responsibility for their actions. (4) Medication errors can occur in the prescribing, dispensing or administration of medicines. Intravenous medication errors have moderate to severe results for patients. (5) The consequences can also be serious for the health professional involved. (6) At a local level at Bart's and the London Trust (BLT), medication errors/incidents are reported through the datex information system in pharmacy. This information is reviewed and analysed by the Medicines Safety Team, which then identifies risk management issues and training needs. It has been identified that the direct cost of medication errors in hospital may be £200-400 million per year. (7) To this must be added the indirect costs such as those arising from litigation.

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Adverse incidents

Adverse incidents associated with infusion devices can occur for a number of reasons, including failure of the device itself, user error, inadequate servicing and maintenance, inappropriate device selection and inadequate instructions for use. User error is the most frequent cause. Between 1990 and 2000, 6773 incident reports associated with infusion and transfusion devices were received by the Medical Device Agency. (7) These included 85 fatalities.

In an analysis of 700 infusion errors, 700 were associated with syringe pumps and a large proportion of these were due to error rather than failure of equipment. Due to underreporting it is likely that the actual number of medication errors associated with infusion devices is at least five times the number actually reported. (RPSGB 1993 in 6) Typical user errors with infusion devices include:

• Misloading the giving set or syringe.
• Setting the wrong rate.
• Confusing primary and secondary rates.
• Not confirming the set rate.
• Not confirming the pump type or syringe size.
• Not stopping the pump correctly.
• Allowing free flow of fluid when lines are removed or fitted.
• Unskilled or irregular servicing.
• Inadequate testing after servicing.
• Interference by patients or visitors. (6)

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Infections

Infection problems associated with the insertion and maintenance of peripheral and central IV catheters are one of the most common and dangerous problems that can occur.  (8) Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, including local site infection, septic thrombophlebitis, endocarditis and other metastatic infections e.g. lung abcess, brain abscess, osteomyelitis. (9)

Catheter related blood stream infection and sepsis are a significant cause of morbidity and mortality in England and Wales. Every year, in the UK, 6,000 patients acquire a catheter related blood stream infection. This worsens the severity of the patients underlying ill health, prolonging the period of hospitalisation and increasing the cost of care. (10) Bacteraemias are associated with a 25% attributable mortality rate. MRSA bacteraemia data now forms part of the mandatory reporting requirements of Acute NHS Trusts in the UK.

It is essential that all health care staff who administer intravenous therapy are competent and safe in their practice. Guidelines for infusion therapy are available from the Trust and a variety of "experts". (2, 11) As well as the Bart's and the London NHS Trust policy, these guidelines provide an evidence base for preventing complications relating to IV therapies.

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References

Progress in Practice: June 2004.

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Page last update by D E Barnett 3/12/2005

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