Unintended bolus of medication if infused at speed from residual space in giving set

Through its core work to review recorded patient safety events, the National Patient Safety Team identified a report outlining the possibility for delivery of an unintended bolus of intravenous medication.

A patient was given a fluid infusion at the end of their surgical procedure using the same intravenous (IV) line that had been used earlier to administer potassium. The patient experienced a cardiac arrest when the residual potassium within the IV line was pushed through as an unintended bolus when the fluid administration commenced.

If the same IV line is used to administer subsequent infusions there is a risk of a bolus effect from any residual medicine in the infusion set, especially if the second infusion is given more quickly than the first.

The team asked the National Infusion and Vascular Access Society (NIVAS) to include information in the revised NIVAS Infusion flushing guideline specifying that to avoid this risk, clinical staff should either change the IV set or ensure the rate of administration of a flush or subsequent infusion is the same as the rate of administration of the medicine.

We subsequently promoted the published NIVAS guidance with the National Association of Medical Device Educators and Trainers (NAMDET) with a request that NAMDET highlight this particular concern as part of their training and education remit.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.