Establishing care bundles is not enough to support patient safety; suitable systems are also needed to support these care bundles and to ensure that the required equipment is available at the point of need. The reliability with which appropriate equipment was available for peripheral intravenous cannulation, as defined by the cannulation care bundle plus additional requirements for tourniquets and sharps bins, was low. Levels of reliability were similar (80.3%; 88.7% and 88.2%) across three study organisations, but the types of failure were highly variable. In organisation A the main issues were lack of a clean tourniquet and sharps bins; in organisation D, it was availability of dressings and in F, it was sharps bins. This indicates that the problems are not insurmountable as at least one organisation had no failures in each category.
We found that the supply chain set up to deliver the correct equipment for peripheral venous cannulation in our study sites was based on old-style routine reordering systems. There were no apparent feedback loops to ensure replenishment of stocks.
The resulting harm due to these equipment problems is unknown, although staff perceived it to be low. The availability of an empty sharps bin and the correct size of cannula appear to be common issues.
This paper is therefore the first to present details of where failures are occurring and potential areas where improvement could be focussed. In particular, the work highlights the many human factors related to the supply chain in intravenous cannulation.
Development of supply chain systems to ensure adequate stock control and availability and replenishment of full sharps bins may improve the reliability of availability of equipment. The need for extra, or different, cannulae during a procedure should also be taken into account when designing cannulation packs. Communication along the supply chain was a key issue. Interviews highlighted the requirement for those responsible for ordering, supply and restocking to be aware of the needs of frontline staff. Staffing issues can cause problems with restocking, particularly if restocking is seen as a particular person’s responsibility (or no-one’s). The lack of sharps disposal bins often resulted in staff taking their sharps to another location for disposal increasing the risk of needlestick injuries to themselves. It may also be that staff familiarity with the type of equipment used has an impact on patient safety, in which case it is important that this be factored into the equipment that is made available. The use of equipment packs will be influenced by their design and way in which they are stored on the ward.
Strengths and limitations
The strengths of our study are that we used a nationally-accepted care bundle and so results represent reliability against agreed standards, with the additional requirement for a clean tourniquet and sharps bin. We also used the same definitions and methods in each of three organisations, thus facilitating comparison. In relation to limitations, equipment availability was measured using self-reporting which may be open to bias, although we believe that this was minimised by anonymity and clear explanation of the purpose of the study, focusing on systems rather than individuals. The assessment of the impact on patient safety was based on the subjective opinion of the staff involved. Adverse events are likely to be rare, and remote from the original cannulation, and so staff may not be able to accurately predict the risks. We also assessed risks from the patient’s perspective and so will not have captured the risks to staff resulting from unavailability of sharps bins, resulting in staff transporting used sharps around their clinical area. There were some differences between organisations in the clinical areas studied. Interviews were few in number, due to the limited time frame available to complete all interviews on all sites; demands on staff meant that interviews often got cancelled at short notice. Finally, generalisability to other hospitals, and in particular to other countries, is unknown.
It appears that the majority of issues would be resolved if:
Standardised packs were used, but available with a variety of cannula sizes, as well as back-up supplies.
The use of disposable tourniquets may increase reliability if incorporated into the packs; there is also evidence that reusable tourniquets are associated with the risk of infection[14, 15].
Systems should be developed to ensure reliable restocking, including systems to inform those responsible for restocking supplies when supplies are low.
Equipment is stored as locally as possible to the location where cannulation is being undertaken.
Effective team work and communication is needed to ensure restocking when replenishment is required, and so that those responsible for restocking are aware of the consequences of the stock not being available, or of sharps bins not being available.
A basic pack of equipment in a trolley which also includes spares, more variable equipment and sharps disposal facilities, which is taken to the patient and then returned to a central restocking point may resolve many of these issues. Such solutions should include consultation with users.
More in-depth study would be required across multiple organisations to determine whether the failure modes in the study organisations are representative of the wider NHS. The Department of Health audit tool for measuring staff compliance with peripheral cannulation care bundle may not detect work-arounds which have the potential to increase risk as it examines whether or not actions are completed. It may be improved by a simple root cause analysis to determine whether equipment non-availability was a contributory factor to actions not being completed, and how availability could be improved. It is likely that availability of sharps bins may be a significant problem and organisations should look at how to make these readily available at the point of care.