Hi! A group of healthcare professionals, industry and human factors experts, predominantly based in the UK, are planning to set up a project to address the known risk of inadvertent use of glucose infusions to flush arterial lines. This is being led by The Chartered Institute of Ergonomics and Human Factors (CIEHF) and chaired by Brian Edwards who also chairs ISoP.

As you know, inadvertent use of glucose infusions to flush arterial lines can result in falsely elevated blood glucose readings when blood samples are drawn from the arterial line which, in turn, may lead to unnecessary insulin administration which dangerously reduces blood glucose. Patient safety incidents have been reported where patients have died or have experienced serious harm because of neuroglycopenic brain injury as a result and this has been the subject of a former National Patient Safety Alert and, later, MHRA guidance in the UK (https://www.gov.uk/drug-safety-update/glucose-solutions-false-blood-gluc...)

We are trying to get as broad a view of the problem and the issues involved as possible and would really appreciate hearing from MSOS members about your experience and what measures your organisation has in place to mitigate the risk.

Thanks in advance!

Pat O'Brien,
Medication Safety Coordinator,
Galway University Hospitals.