Arterial Blood Gas Sampling:
In intensive care and operating theatres, blood samples are frequently taken from arterial lines to measure a patient’s blood chemistry.
Arterial lines are maintained with a saline flush solution but in some instances a glucose containing flush solution may be accidentally attached. A blood sample taken in this scenario would result in an artificially high blood glucose measurement.
Without realising the error clinical staff may be misguided down an inappropriate treatment pathway, administering insulin for hyperglycaemia. This can result in the patient developing hypoglycemia which can lead to fatal brain injury.
The National Patient Safety Agency regularly receive reports of such errors. They have issued an alert highlighting the error and recommended the development of safety solutions to prevent this error [3].
[3] National Patient Safety Agency. Rapid Response Report, PSA/2008/RRR006,www.weahsn.net/wp-content/uploads/Problems-with-infusions-and-samplingfrom-arterial-lines-NPSA-Rapid-Response-Report-2008.pdf
