The National Patient Safety Agency (NPSA) has issued a Rapid Response Report (RRR) alerting NHS organisations in England and Wales to the risk of the accidental over infusion of intravenous fluids and medicines to neonates.
Accidental over infusion of intravenous fluids and medicines to neonates can occur during the setting up of specific intravenous infusions or as a result of the overriding of safety mechanisms on infusion pumps and has the potential to result in death. The report asks clinicians to ensure that a local neonatal intravenous administration policy is available and that it specifies:
• When using a syringe pump to administer intravenous fluids or medicines to neonates, a bag of fluid should not be left connected to the syringe.
• All clamps on intravenous administration sets must be closed before removing the administration set from the infusion pump, or switching the pump off. This is required regardless of whether the administration set has an anti-free flow device.
• The frequency and responsibility for monitoring: the intravenous infusion device, the infusion administration equipment and the patient receiving intravenous infusion.
The NPSA’s Patient Safety Lead for Child Health, Jenny Mooney, said: “The administration of intravenous fluids and medicines to neonates is often an integral part of their care. The weight and size of the baby and the often critical nature of their medical condition are additional risk factors within this process.” The RRR is available from the NPSA website: www.nrls.npsa.nhs.uk
