Problems Associated with Vascular Access: An Analysis of 2000 Incident Reports

Abstract

There were 65 incidents involving access to the vascular system amongst the first 2000 reported to the Australian Incident Monitoring Study. Thirty-three involved peripheral venous access (14 cases of extravascular extravasation, 8 of unintended arterial cannulation, 6 of disruptions to intravenous lines, and 5 of problems with infusion lines, taps, pumps and connectors). Eighteen cases involved central venous access (9 cases of arterial puncture with haematomas, 5 with morbidity and/or prolonged admission), 5 of catheter misplacement and pneumo-or hydro-thorax and 4 of problems arising from operator inexperience. Thirteen cases involved peripheral arterial acces (5 involved equipment problems (3 with possible air embolism), 3 of mistaking an arterial for a venous line (drugs were injected in 2), 3 of losing arterial lines or signals, and 2 in which the presence of an arterial line placed the patient at risk}. The anaesthetist should always question the continued integrity of any vascular access system, even when it has recently been shown to be functioning, and the possibility of later "migration" and misplacement should always be borne in mind. Whenever possible, correct placement of the tip should be checked (e.g. by visual inspection of the site, use of test doses, aspiration of blood, pressure measurement, X-rays). When there is more than one line, aI/lines and sites of access (e.g. 3-way taps) should be clearly labelled and checked before anything is injected or infused.

Incidents associated with mechanical ventilation and intravascular catheters in neonatal intensive care: exploration of the causes, severity and methods for prevention

“…For instance, one unit mentioned the implementation of different colours for the securing of catheters, after reports of accidental removal of a silestic catheter instead of the peripheral infusion catheter (table 3). This type of intervention has already been used in other NICUs and has also been described previously 17. Although our study would allow comparison of incident types and identified root causes between different NICUs, we did not report this information for reasons of confidentiality.…”

Review of the Australian Incident Monitoring System

“…Three of the Specialty AIMS users referred to publications [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] and seminar presentations of AIMS data as evidence for the utility of the system in identifying problems that require action. Significant changes had been introduced in 71% of facilities using Generic AIMS and in 100% of Specialty AIMS users.…”

Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation

“…The Australian Incident Monitoring Study has reported that 50% of central line incident reports are due to inadvertent arterial injuries which have led to increase patient morbidity and/or prolonged hospital stay [14]. Even under direct ultrasound guidance using either the short or long axis if the needle passes outside of the ultrasound beam, the tip may actually be deeper than suspected and may pass through the posterior wall of the vein [15] into deeper unseen structures such as the carotid artery.…”