Patricia Steer

“Neither the staff nurse who changed the catheter nor the supervising senior staff nurse who was present throughout the procedure were aware of the risk of air emobilization in the process of changing the catheter, where as it was in this case, left uncapped and unclamped. Whilst the attending Consultant was aware of the risk, the Serious Incident Investigator identified that it had not been possible to locate any literature or guidance on this point, having contacted other Trusts, and making an extensive”