Intravenous (IV) infusion systems pose the greatest risk of medical error in magnet hospital systems.(1) To prevent IV-related medical errors, hospitals have implemented practices and protocols to protect patients from the dangerous risk of infections, needlesticks and infiltrations. One area that has been overlooked, however, are protocols and systems for avoiding dangerous air intrusion.
A survey of risk managers and patient safety officers at the 2018 IHI/NPSF Congress confirmed hospitals do not have practices in place to protect patients against the dangerous risk of air in IV lines, or air burden. The standard protocol relies on visual inspection and manual intervention by clinicians.
The survey results indicated:
- 100% hospitals have protocols for reducing infections
- 71% hospitals have protocols for reducing needle sticks
- 54% hospitals have protocols for reducing infiltrations
- 0% hospitals have protocols for eliminating air burden and avoiding air embolism
None of the hospitals surveyed reported any practice other than clinician observation to avoid the preventable damage caused by the number #2 Hospital Acquired Condition, Air Embolism, and the clinical consequences caused by Air Burden.
Air burden, or any amount of air infused to patients, is a preventable event with minor to serious clinical outcomes. Clinical consequences may include a range of outcomes, from migraines to paralysis, coma and death. Pediatrics, critically ill patients, and patients with a congenital heart defect or Patent Foramen Ovale (PFO) are at a high risk for serious clinical consequences from even small amounts of air in IV lines. One out of four people have a PFO – and the condition is rarely diagnosed until an event occurs.(2)
The current standard of care of visual inspection for removal of air from IV lines relies too heavily on manual intervention and is far from standardized. Better systems and tools are required to protect patients from this avoidable event.
ClearLine IV is the only FDA cleared device for the automatic detection and active removal of air from IV lines. The device was recently FDA cleared in January 2018 and received the 2018 Patient Safety Innovation Award by the Patient Safety Movement Foundation. The device is used by leading healthcare institutions across the nation to protect patients from the risk of air embolism and air burden.