Project Archive

Residual medications: Silent threat, visible solutions

Following a critical incident in which a needle-free injection port attached to a 20G cannula containing residual Suxamethonium was flushed into an adult patient, leading to respiratory arrest, a regional survey was conducted to measure awareness of the potential risk of retained medications in adults.

​

The findings were: over one quarter of our region’s Anaesthetists did not routinely flush drips in adults before transfers to the recovery area; many were not aware of the risks of retained medications in the dead-space of “octopus” needle-free connectors.

​

A poster campaign in one theatre complex, educating Anaesthetists about the need to flush their drips, improved flush rates from 68% to 98.4%, using retained propofol in the drips as a surrogate for flushing before and after the campaign.