A response

Abstract

I was immediately struck, on reading this report, by its similarity to a case published in Anaesthesia in 2007 [1]. An arterial line set up inadvertently with a 5% glucose flush had led to an erroneous diagnosis of hyperglycaemia in an ICU patient recovering from multiple organ failure. Insulin had been administered accordingly and, by the time the error had been detected, cerebral damage had occurred which sadly proved fatal. The authors had carried out a comprehensive root-cause analysis, reaching, inter alia, the same conclusions as Drs Brewer and Williams, and reported the incident to the National Patient Safety Agency (NPSA). An accompanying editorial commented on this case and two other critical incidents reported in the same issue of Anaesthesia [2]. The NPSA subsequently issued a ‘rapid response report’ indicating that they were aware of two deaths and 82 other incidents relating to wrong infusion fluids being used for arterial line flushes, and offering guidance on preventing further episodes, including ensuring that bag contents/labels could be seen even if pressure bags were in use (although they gave no advice as to how this might be achieved) [3]. I applaud Drs Brewer and Williams for reporting this case. However, I am sure that they were not alone in being apparently unaware of the previous publication and, more importantly, of the NPSA guidance. In my view, we have successfully moved over a period of 10–15 years from a culture where we hid our errors away, to one where incident reporting is commonplace and praiseworthy, and where we now have an efficient National Reporting and Learning Service. So how do we close the final, critical part of the loop and make sure that front-line clinicians are aware of, and act upon, the advice that follows?