Accidental hypoglycaemia caused by an arterial flush drug error

We read with great interest the recent articles about iatrogenic neuroglycopenia 1-3 and the Association of Anaesthetists of Great Britain & Ireland's guidelines 4. The authors should be complimented for their exceptional effort in further raising the profile and magnitude of this ongoing problem, which continues to put patient at risk despite the National Patient Safety Agency alert of 2008 5. We also viewed the articles with self-reproach, as we had encountered a similar incident in our Trust in 2012. We have implemented a series of changes following this and other incidents, including mandating the use of 500-ml bags of saline 0.9%, a signed, designated prescription sticker and double-checking before connection. Although seemingly robust, this response was still not enough. As with the author's report, we also found ongoing problems caused by the pressure infusor cuffs in use: despite being ‘transparent’, they obstruct a clear view of the labelling on the fluid bags. In developing a response to this issue we came across three different, commonly available types of pressure infuser cuffs (Fig. 7): As in Gupta and Cook's report 3, a contributory factor in our incidents was the potential for the net-sided pressure bag (type 1, above) to obscure the labelling and contents of the infusate. Clear pressure infusor cuffs (type 2) should have been the chosen option in our response, but we found a significant issue with both types listed: neither cuff is manufactured to fit the Viaflo fluid bags we use as standard (Baxter, Deerfield, IL, USA), resulting in herniation of the bag or cuff failure. Unfortunately, this only became evident when these infusor cuffs were introduced into practice. We opted for clear-sided pressure infusor cuffs (type 3). These are of low cost, re-usable (unless soiled) and provide an unhindered view of the labelling and contents of the entire infusate, albeit on one side only. They also seem to be manufactured to fit all available types of fluid bag. In conclusion, we insist that all fluid pressurising devices should at least have a fully transparent front panel 4 and must be checked for the compatibility with the fluid bags used.