You attend a cardiac arrest on the ward. The nurse, who was ambulating the patient after their fluids were disconnected, informs you the patient had rapidly deteriorated. That is when you notice the central line lumens had been left open to air. Your suspicions of air embolus are supported on echocardiography, however despite resuscitative attempts the patient dies in ICU two days later. The unfortunate nurse involved subsequently quits nursing altogether.
We estimate from worldwide reports there is at least one death every day from a central line air embolus – all cases are avoidable. (see here)
Awareness about this issue is poor, and solutions so far implemented have had limited effect. We need to appreciate the complexity of our work environments and apply human factors engineering if we are to prevent these iatrogenic complications.
The power is in your hands to make a difference. Review and implement these 5 effective solutions:
- Vascular Access Decision Tree
- Centralised Education and Training
- Awareness Campaign
- Central Line Management Form