The Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs) is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.
Safety Monitor, this column in AJN from PA-PSRS, informs nurses on issues that can affect patient safety and presents strategies they can easily put into practice.
Visit the Web site of Pennsylvania's Patient Safety Authority, at http://patientsafetyauthority.org for information on extravasation of radiologic contrast agents and useful resources in developing extravasation protocols. Refer to "Patient Safety Advisories" in the left-hand navigation menu. Then click on "Advisory Library," select the September 2004 issue of the PA-PSRS Patient Safety Advisory and click on "Extravasation of Radiologic Contrast."
For the original articles discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.
The purpose of IV infusion therapy is to deliver fluid, electrolytes, medications, blood products, or prolonged nutritional support through a peripheral or central venous catheter. IV infusion pumps can deliver IV infusion therapy continuously, intermittently, or on command (as in patient-controlled analgesia, for example). Infusion pumps are equipped with downstream occlusion sensors that detect elevated pressure in the IV administration set between the infusion pump and the patient. When the sensor perceives the pressure has reached the pump's preset limit, aural and visual alarms go off, and the IV flow stops. Although IV infusion pumps have many safety features, including occlusion alarms, they do not detect or prevent IV infiltration or extravasation, which occur when IV fluid enters an unintended area of the body.
The terms infiltration and extravasation are often used interchangeably, but they have different meanings. The Infusion Nurses Society (INS) defines extravasation as "the inadvertent administration of vesicant medication or solution into the surrounding tissue" instead of into the intended vascular pathway.1 A vesicant is a highly corrosive agent that can cause blistering, tissue necrosis, or both. Vesicants include certain hazardous medications, including chemotherapy agents, certain antibiotics, certain antiemetics, certain vasopressors, parenteral nutrition formulas, radiocontrast media, and some electrolyte solutions (as well as other compounds).2, 3 The INS defines infiltration as "the inadvertent administration of nonvesicant medication or solution into the surrounding tissue" instead of into the intended vascular pathway.1
The following accounts from the Pennsylvania Patient Safety Reporting System identify instances of IV infiltration or extravasation associated with IV infusion pumps.
Many of these reports imply that nurses incorrectly believe that pumps will alert them to infiltrations and extravasations. However, infiltration and extravasation typically occur at much lower pressures than occlusion alarms are set to recognize, and they will therefore not trigger an alarm.4 Further, if a pump's limit is set too low, the alarm could become a nuisance to the patient and nurse. Or the alarm might signal a downstream occlusion caused by conditions other than infiltration or extravasation (such as kinked IV tubing between the pump and the patient or a blocked IV port site).
Nurses can use the following risk-reduction strategies to decrease the likelihood of infiltrations and extravasations or reduce the damage they cause.
Monitor the IV site frequently to ensure correct catheter or needle placement. Don't rely on the IV infusion pump's downstream occlusion alarm to alert you to an infiltration.
Assess the patient's skin routinely for signs and symptoms of IV infiltration and extravasation. And know your facility's policy on how often to perform the skin assessment and how to document your assessment.
Recognize early signs of infiltration and extravasation associated with IV infusions. The INS has published an infiltration scale (see Table 1) that can be used to grade an infiltration (extravasations are always given the most severe grade).1 When signs of infiltration are first observed, stop the infusion therapy and immediately remove the catheter.3
| | Table 1. IV Infiltration Grades and their Clinical Criteria |
Initiate treatment according to the severity of the infiltration or extravasation, according to your facility's policy.1, 3 (For detailed information on treatment, see "Infiltration and Extravasation," Emergency, August 2007).
Notify bioengineering personnel after an infiltration or extravasation has occurred, so they can inspect and if necessary repair the IV infusion pump. Any service provided should be documented.4
IV infusion pumps play a secondary role in infiltration or extravasation events, which are typically caused by mechanical means, such as the needle puncturing the vein wall or dislodging from the implanted port, obstructed blood or fluid flow, or an inflammatory reaction such as chemical irritation from medications.1, 3 Prompt identification and treatment of infiltration and extravasation will occur with frequent assessment and monitoring of IV sites rather than exclusive reliance on IV infusion pump alarms. Technology is available to enhance patient care, but nurses must always assess the patient directly to ensure the safe delivery of IV fluids.
1. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs 2006;29(1 Suppl):S1–S92. [Context Link]
2. Hadaway LC. Preventing and managing peripheral extravasation. Nursing 2004;34(5):66–7. [Context Link]
3. Hadaway L. Infiltration and extravasation. Am J Nurs 2007;107(8):64–72. [Context Link]
4. [No authors listed]. Infiltration during infusion therapy. Health Devices 1998;27(1):39. [Context Link]
5. Polovich M, et al., editors. Chemotherapy and biotherapy guidelines and recommendations for practice. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2005.
A periodic column from the Pennsylvania Patient Safety Reporting System
Source : AJN, American Journal of NursingApril 2009
Volume 109 Number 4
Pages 32 - 33
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