Venous Needle Dislodgement: Technological Solution to Fatal Hazard?

As dialysis practices evolve to treat some patients at home with less supervision, new threats to safety emerge and existing risks may increase. The threat of venous needle dislodgement and access-bloodline separation is included in ECRI’s Top 10 Health Technology Hazards for 2023:

“Potentially life-threatening hazards can occur during hemodialysis, including the venous needle becoming dislodged at the vascular access point or the central venous catheter becoming separated from the bloodline used for treatment. Either event can very quickly lead to a massive loss of blood, and thus severe injury or death.

Often, such events cannot be detected by a hemodialysis machine’s venous pressure monitor—and so will not produce an alarm. Dislodgements or detachments can be caused by, for example, a person tripping on a bloodline, a line snagging on an object during patient movement, or someone pulling on the line (either knowingly or unknowingly). Such occurrences, which likely are underreported, are of particular concern if dialysis is being provided in the home or some other location where a trained caregiver is not available to respond immediately.” (ECRI’s Top 10 Health Technology Hazards for 2023).

ECRI’s team of biomedical engineers is currently evaluating a device that claims to mitigate the problem and increase patient safety. But do the results hold up to the hype?

Learning objectives

• During this lab webcast, we will discuss:
• Why undetected venous needle dislodgment is a growing safety concern
• What technology is currently available to address the issue
• Methodology utilized in evaluating the technology

Register to view the recording

Speakers

Anna L. Thomas MSN, RN, CCRN, CPPS, CNL

Patient Safety Analyst III, ECRI
Anna started her career as a critical care nurse in a neuroscience intensive care unit. She earned a master's of science in nursing (MSN) and became a certified clinical nurse leader (CNL). She served as a CNL for a 12 bed ICU where she was responsible for nursing sensitive quality indicators, risk mitigation, cost reduction, event reporting and analysis, and utilizing data to drive quality improvement projects. She chaired the Evidence Based Practice and Nursing Research committee. In her current role, she utilizes her clinical background to review ECRI publications to ensure the most accurate and current information, has redesigned the research response process, and was on the inaugural Safety Sprint team focusing on mitigating the staffing shortage. As co-chair of the Causal Analysis team, she is responsible for data collection and analysis for multiple forms of causal analysis.

Jason Launders

Director of Operations, Device Evaluation, ECRI
Jason Launders has been at ECRI since 1998 and is currently the Director of Operations for the Device Evaluation group. Launders’ primary responsibility is managing ECRI’s laboratory-based evaluations of medical technologies. He holds a master's degree in medical physics and spent his earlier time at ECRI evaluating a wide range of diagnostic imaging technologies, such as CT, MRI, PACS, and digital radiography. Today, he is responsible for developing the content of evaluations to ensure they meet the needs of our clients.

Ismael Cordero

Senior Project Officer, Device Evaluation, ECRI
In his current role, Ismael Cordero's focus is the evaluation of medical devices used for intensive care and respiratory therapy. Before joining ECRI, Cordero worked in more than 50 countries where he led many training and consultative activities for biomedical engineers and technicians, clinical personnel, and hospital administrators. These activities included collaborations with the American College of Clinical Engineering (ACCE) and the World Health Organization (WHO). He was the recipient of the 2008 ACCE Professional Achievement in Management Award and the recipient of the 2014 AAMI Foundation & ACCE’s Robert L. Morris Humanitarian Award. Cordero holds a BS in biomedical engineering technology from Temple University in Philadelphia, Pennsylvania, USA.