Why has NHS England introduced an innovation and technology tariff to improve safer arterial systems in England?

Editor—Arterial transducer infusion sets are associated with complications such as bacterial contamination and accidental arterial injection, potentially leading to bacteraemia, tissue necrosis and limb loss.¹ In recognition of reported complications, the NHS England National Patient Safety Agency (NPSA)² has issued warnings on the risks associated with accidental arterial injection, and the Joint Commission and the World Health Organization (WHO) have stated that injection ports on arterial catheters should be avoided.³ In England, after the 2008 National Awareness Alert, the NPSA required NHS hospitals to take immediate action and introduce safety systems that included training, audit, labeling of the arterial line and using red coloured transducer sets. Whilst these measures are helpful in reducing error, they do not prevent accidental arterial injection of medication intended for venous administration. Seven years after the NPSA alert we conducted a simulation study which illustrated mis-injection into the arterial line where, despite colour coding and labeling of standard arterial transducer sets, 2/3 study participants made this error in an emergency situation.⁴ From January 2008 to August 2015, there have been 155 reports of this error to NHS England (Keogh B, Medical Director and Durkin M, National Director of Patient Safety, NHS England, personal communication, 2015). However, it is likely that the error is under-reported as ischaemic complications are delayed for hours in the unconscious patients by which time the incident is forgotten, denied or obscured, and national reporting is not mandatory.

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