venous needle dislodgement in patients on hemodialysis

Nephrology Nursing Journal November-December 2012 Vol. 39, No. 6 435

Venous Needle Dislodgement In Patients on Hemodialysis

Hemodialysis treatments havebecome routine, but complica-tions still occur, ranging fromthe most common (headache,

cramps) to the less frequent yet moreserious complication of substantialblood loss related to venous needledislodgement (sometimes abbreviat-ed as VND). Venous needle dislodge-ment happens when the venous fistu-la needle becomes dislocated out ofthe vascular access, resulting in bloodloss. This can lead to a rapidly declin-ing blood volume in the patient andmay cause morbidity and mortality ifnot discovered quickly. At typical hemo -dialysis blood flow rates of 400 to 500mL/minute, it can take only minutesfor the patient to lose over 40% of hisor her blood volume (the point atwhich hemorrhagic shock occurs)(Gutierrez, Reines, & Wulf-Gutierrez,2004). In a scientific ab stract presentedat the 2008 American Society of Neph -rology (ASN), Sandroni, Sherockman,

Billie AxleyJoan Speranza-ReidHelen Williams

Continuing NursingEducation

Billie Axley, MSN, RN, CNN, is Director,Quality and Initiatives, Fresenius Medical Care,Franklin, TN, and a member of ANNA’s Music CityChapter. She may be contacted directly via e-mail [email protected]

Joan Speranza-Reid, BSHM, RN, CNN, isDirector of Renal Services, CVPH Medical Center,Plattsburgh, NY, Hemodialysis Special PracticeNetwork Facilitator for ANNA, and a member ofANNA’s Northeast TriState Chapter.

Helen Williams, MSN, RN, CNN, is anAssistant and Special Projects Manager, DenverAcute Dialysis, Fresenius Medical Care, Denver,CO, Commissioner the Nephrology NursingCertification Commission, and a member ofANNA’s High County Chapter.

Statement of Disclosure: The authors reported noactual or potential conflict of interest in relation tothis continuing nursing education activity.

This offering for 1.4 contact hours is provided by the American Nephrology Nurses’Association (ANNA).

American Nephrology Nurses’ Association is accredited as a provider of continuing nursingeducation by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider numberCEP 00910.

Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.

This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-ing nursing education requirements for certification and recertification.

Copyright 2012 American Nephrology Nurses’ Association

Axley, B., Speranza-Reid, J., & Williams, H. (2012). Venous needle dislodgement inpatients on hemodialysis. Nephrology Nursing Journal, 39(6), 435-445.

Venous needle dislodgement is a potential serious complication of hemodialysis therapy.In 2012, the American Nephrology Nurses’ Association (ANNA) created a collaborativespecial project workgroup to review venous needle dislodgement occurrence, conse-quences, and recommended practices, and to develop strategies and resources on venousneedle dislodgement to be used by nephrology nurses and other healthcare professionals,as well as by patients and their families. The ANNA Venous Needle DislodgementSpecial Project Workgroup conducted a literature review and also surveyed nephrologynurses about their experiences with venous needle dislodgement and their recommenda-tions for needed resources. This article discusses the results of the literature review andsurvey, and provides resources on venous needle dislodgement, including a venous nee-dle dislodgement risk assessment tool, education materials, and practice recommenda-tions.

Key Words: Venous needle dislodgement, hemodialysis, venous access site, endstage renal disease, blood loss, taping techniques, bloodlines, needles,catheters, patient education.

GoalTo provide an overview of venous needle dislodgement in patients undergoinghemodialysis and prevention strategies.

Objectives1. Describe the serious impact that can occur from venous needle dislodgement.2. Explain the findings regarding incidence of venous needle dislodgement as discov-

ered by the ANNA Venous Needle Dislodgement Survey and Literature Review.3. Discuss practice recommendations for nephrology nurses and other healthcare

providers who treat patients undergoing hemodialysis.

Copyright 2012 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any formwithout the written permission of the American Nephrology Nurses' Association.

Nephrology Nursing Journal November-December 2012 Vol. 39, No. 6436

Venous Needle Dislodgement in Patients on Hemodialysis

and Hayes-Light (2008) reportedfrom a study involving 300 patientsan observed incidence in their hospi-tal system of one catastrophic hemor-rhage resulting from venous needledislodgement per 126,718 treatments.The authors indicated if the annualincidence of such events nationallywas similar to the incidence theyobserved, it could be estimated thatover 400 events occur annually in theUnited States (Sandroni et al., 2008).

BackgroundVenous needle dislodgement has

been described as “…a potentiallylife-threatening complication of dialy-sis…” (Hurst, 2011a, p. 148). An advi-sory from the Pennsylvania PatientSafety Authority (2010) indicated that32 event reports involving needle dis-connections were received during aone-year period from November 1,2008, through October 31, 2009.These submitted events represented6.1% of all hemodialysis eventsreported to the Pennsylvania PatientSafety Authority during that period.These data were limited to reportsfrom hospital-operated dialysis facili-ties (Pennsylvania Patient SafetyAuthority, 2010). A Patient SafetyAdvisory from the U.S. Departmentof Veterans Affairs (VA) in 2008reviewed 47 root cause analyses andsafety reports received from March 1,2002, to April 30, 2008, that con-cerned bleeding episodes during thehemodialysis treatment. In this analy-sis, the 47 reported patient events“…involved dislodgement of thevenous needle or disconnection of thevenous bloodline at the dialysiscatheter attachment” (Veterans HealthAdministration, 2008, p. 3). In its2006 End Stage Renal Disease(ESRD) Patient Survey, the RenalPhysicians Association (RPA) (2007)found that 5.1% of the 1056 patientsresponded positively when asked ifthe needle had ever, in the last threemonths, come out of their access sitebefore their dialysis treatment was fin-ished.

Saibu and colleagues (2011) re -ported a patient death resulting from

venous needle dislodgement andadvocated for staff and patient educa-tion concerning the importance ofkeeping the patient’s access visible atall times. Education of all nephrolo-gy/dialysis staff and patients on dialy-sis on prevention of accidental lineseparation and venous needle dis-lodgement were promoted as a “toppriority during hemodialysis” bySaibu and colleagues (2011, p. 515).

The risk of complications fromvenous needle dislodgement is mag-nified by dislodgements that do nottrigger a venous pressure alarm toalert patient care staff or the patient(Sandroni et al., 2008). Venous needledislodgement during hemodialysiswithout triggering a venous pressurealarm was reported in an online med-ical device safety report from 1998that described “…the back pressurecreated by the narrow-bore needlesprevented the machine’s venous pres-sure monitors from sensing the loss ofpressure created by the dislodge-ment” (ECRI Institute, 1998, p 1).The report continued to say that evenif the venous needle is fully or partial-ly dislodged from the patient, thevenous pressure monitor is likely tocontinue sensing the pressure createdby the needle’s flow resistance. Theconclusion of the ECRI Institutereport indicated that although thevenous pressure monitor may be ableto reliably detect a large pressurechange, needle flow resistance makesit “unlikely” for the monitor to detectthe smaller drop in pressure associat-ed with needle dislodgement (ECRIInstitute, 1998). In addressing unde-tected venous needle dislodgement,the ECRI Institute (1998) stated theproblem was not unique to any specif-ic brand or model of hemodialysismachines or tubing sets. The VA, inits Patient Safety Advisory on bleed-ing episodes during dialysis, foundsimilar general information from themajority of its analyzed events. Therewas no statistical difference betweenthe incidence of complications andthe brand of dialysis machine in -volved in their analysis (VeteransHealth Administration, 2008).

Consequences of a venous needle

dislodgement event can range fromminimal blood loss to a fatal hemor-rhage (Pennsylvania Patient SafetyAuthority, 2010). In its analysis ofreports of bleeding during dialysis,the VA National Center for PatientSafety found that 40 of the 47 eventswere termed “serious bleeding epi -sodes” (Veterans Health Administration,2008, p. 1) (which they defined asmore than 100 mL), many of which“required hospital admission andsome resulted in death of the patient”(Veterans Health Administration, 2008,p. 3). A series of articles directed tothe public concerning safety in dialy-sis by Fields (2010) included an articlethat related the story of a patient ondialysis who “never really recovered”from a loss of blood from her venous“tube” and spotlighted the event as a“catastrophic hemorrhage duringtreat ment” (p. 2). Fields (2010) alsoreported that ProPublica examinedrecords for more than 1500 dialysisclinics in five states from 2002-2009and found at least one fatality thatresulted from needle dislodgementsin each of the five states plus “dozensof additional cases in which patientsrequired hospitalization, blood trans-fusions, or other emergency interven-tions” (p. 4). Fields (2010) also de -scribed the compelling physical andpsychosocial suffering of five patientson hemodialysis and their familiesdue to line separations, needle dis-lodgement, and staff error that result-ed in significant blood loss during adialysis procedure. Hurst (2009) hasadvocated that just as fire drills arepracticed and smoke detectors areused to prevent harm, the healthcarecommunity must learn from pastvenous needle dislodgement inci-dents, be vigilant, and use availabletechnologies to provide safe care.

ANNA Venous NeedleDislodgement Special ProjectWorkgroup

The American Nephrology Nurses’Association (ANNA) conven ed a col-laborative special project workgroup,the ANNA Venous Needle Dislodge -ment Special Project Workgroup, to



review recommendations of care forvenous needle dislodgement preven-tion and detection, and to presentthese recommendations in easy-to-usetools. A literature review was per-formed for occurrences and conse-quences of venous needle dislodge-ment and to identify best practice rec-ommendations for prevention ofvenous needle dislodgement. To gath-er information from nephrology nurs-es on the occurrence and implicationsof venous needle dislodgement in thehemodialysis population, the ANNAVenous Needle Dislodgement SpecialProject Workgroup developed theANNA Venous Needle DislodgementSurvey and distributed it to theANNA nephrology nurse member-ship. Questions included in the sur-vey were:• Identification of practice area.• Have you seen a venous needle

dislodgement in the past fiveyears?

• How often are you concernedabout venous needle dislodge-ment?

• Would a screening tool assist youin the assessment of a patient’srisk of venous needle dislodge-ment and be of benefit to you?

• Would educational material onhow to reduce the risk of venousneedle dislodgement be of bene-fit to you?

• Please share additional com-ments about venous needle dis-lodgement.

ANNA Venous NeedleDislodgement Survey Results

Responses were received from1173 nephrology nurses. Over 70% ofrespondents reported they practicedin chronic hemodialysis and 43.1% inacute care (the percentages exceeded100% because respondents wereasked to identify all areas in whichthey practice) (see Table 1). TheANNA Venous Needle DislodgementSurvey results revealed that 76.6% (n = 894) of the 1166 responders tothe survey question about observanc-es of venous needle dislodgementindicated they had seen a venous nee-dle dislodgement in the past fiveyears, with 8.2% (n = 96) of these hav-ing seen five events or more in thistime period (see Table 2). Slightlymore than half (57.9%) of the 1162respondents to the question of howoften they were concerned aboutvenous needle dislodgement indicat-

ed they were concerned about venousneedle dislodgement very often oroften (see Table 3). An additional23.1% rated their concern as occa-sional. Of the 1156 survey respon-dents to the question about the poten-tial benefit of a venous needle dis-lodgement risk assessment, 71.2% (n =823) indicated they would find such atool to be beneficial. To the questionabout the benefit of education materi-al on how to reduce the risk of venousneedle dislodgement, a resounding85.3% (n = 996) of the respondersindicated that education materialwould be of benefit. The survey alsooffered respondents the opportunityto share additional comments aboutvenous needle dislodgement. Therespondents of fered their views of cri-teria for patients they thought were atrisk for venous needle dislodgement,factors that contributed to thepatient’s risk, and interventions they

Table 2ANNA Venous Needle Dislodgement Survey: Observed Venous Needle Dislodgements

Have you seen a venous needle dislodgement in the past five years?

All RespondentsAcute Care

Practice AreaChronic Hemodialysis

Practice Area

Yes, 1 to 2 times 50.0% (583) 52.0% (262) 50.0% (412)

Yes, 3 to 4 times 18.4% (215) 16.3% (82) 21.4% (176)

Yes, 5 or greater times 8.2% (96) 8.7% (44) 8.8% (72)

No 23.3% (272) 23.0% (116) 19.8% (163)

Total Respondents to the Question 1166 504 823

Table 1ANNA Venous Needle Dislodgement Survey:

Respondent Practice Areas

Chronic Hemodialysis 70.7% (827)Acute Care 43.1% (504)Nursing Education 8.4% (98)Continuous Renal Replacement Therapy 8.3% (97)Therapeutic Apheresis 4.4% (51)Pediatric Nephrology 3.7% (43)Other Areas with less than 3% 11.7% (140)

*Respondents were asked to list all of their practice areas. There were 1783responses from 1170 respondents, indicating that many respondents work in multi-ple areas.




perceived would reduce that risk. Theliterature review supported the infor-mation obtained in the ANNAVenous Needle Dislodgement Surveyre sponses.

Information from the ANNA VenousNeedle Dislodgement Survey andThe Literature Review

Assessment of the Risk Van Waeleghem, Chamney, Lindley,

Olausson, & Pancirova (2008) recom-mended that all patients be assessedfor their level of risk for venous nee-dle dislodgement. Risk factors associ-ated with venous needle dislodge-ment have been identified in theANNA Venous Needle DislodgementSurvey along with multiple journalarticles and publications reviewed inthe literature review (see Table 4)(Amato, Hlebovy, King, & Salai,2008; Gomez, 2011; Hurst, 2009,2011a; Laird, 2011; Lindley, 2005;McCabe, McArtney, Lomas, & Moir,2009; Sandroni, 2005; Sandroni et al.,2008; RPA, 2007).

Confused, restless, agitatedpatients; patients who are cogni-tively impaired; and patients withdementia.• The VA analysis of root cause

analysis and safety reports ofbleeding during dialysis at VAdialysis centers found that “75%of the most significant bleedsoccurred in patients who wererestless, confused, agitated, oruncooperative” (Veterans HealthAdministration, 2008, p. 1).

• Lascano and Anderson (2011)reported that high-acuity patientswith altered mental status are at ahigher-than-average risk for ve nousneedle dislodgement. This in -cludes patients who may be con-fused because of Alzheimer’s dis-ease. Other conditions, such assedation or infection, can alsolead to an altered mental state.Patients with a reduced level ofconsciousness and communica-tion challenges may not be ableto alert staff to a problem.

Patients who experience hypo -tension or muscle cramps duringtreatment.• Needle security is at risk with

excessive movement of the ac -cess limb.

• The patient may become dia -phoretic, causing the tape toloosen.

Patients who refuse to keep theaccess areas and bloodlines uncov-ered.• Lascano and Anderson (2011)

addressed the importance of en -suring that the patient’s accessand needles are visible at alltimes.

• The issue of patients who fallasleep with their access covered,resulting in unintended accesslimb movement and dislodgement,was mentioned multiple times asa risk for venous needle dislodge-ment in the ANNA Ve nousNeedle Dislodgement Survey.

• Visibility was noted as an issue inthe VA analysis (Veterans HealthAdmini stration, 2008).

• Intentional dislodgement by apatient was mentioned severaltimes as a risk in the ANNA Ve -nous Needle Dislodgement Survey.

Taping technique.• ANNA Venous Needle Dislodge -

ment Survey respondents repeat-edly indicated that taping tech-nique was critical to preventvenous needle dislodgement.Factors related to securing theneedles included an access that isin a difficult location or has adeep angle of cannulation.

• A Cleveland Clinic improvementproject included training staff onanchoring needle taping tech-nique (Lascano & Anderson,2011).

• Preparing the skin and the cor-rect technique for the secure tap-ing of the access needles areaddressed in the ANNA CoreCurriculum for Nephrology Nursing(Dinwiddie, 2008).

• The ANNA Venous Needle Dis -lodgement Survey results in di -

How often are you concerned about venous needle dislodgement?

Very Often 34.8% (404)Often 23.1% (269)Occasionally 23.1% (269)Seldom 17.8% (207)Never 1.1% (13)

Total Responses 1162

Table 3ANNA Venous Needle Dislodgement Survey: Concern about Venous Needle Dislodgement

Table 4Summary of Risk Factors Associated with Venous

Needle Dislodgement

• Confused, restless, agitated patients; patients who are cognitively impaired,and patients with dementia

• Patients who experience hypotension or have muscle cramps during treatment• Patients who refuse to keep the access areas and bloodlines uncovered• Taping technique • Staff observation • Patients on nocturnal and/or home hemodialysis



cated that patients with excessivehair in the access taping areasmay experience loosening of thetape securing the needle(s) duringthe hemodialysis treatment. Oneexperience with tape seeming tolose its adherence to the patient’sskin was described as looseningover time into the treatment.

• Patients who experience sweating(such as the sweating that canoccur with hypotension or in apatient with diabetes who experi-ences hypoglycemia) have beenidentified as at risk for looseningof the tape that is securing theneedles (Van Waeleghem et al.,2008).

• The ANNA Venous Needle Dis -lodgement Survey respondentsindicated even a small amount ofleakage around the needle sitecan cause tape to become loos-ened, increasing the risk ofvenous needle dislodgement.

Staff observation.• Patient observation by the staff

was noted as a risk factor by res -pondents to the ANNA VenousNeedle Dislodgement Survey.

Staffing.• Ensuring adequate staff-to-patient

staffing ratios to allow routinemonitoring of the patient’s accessduring the hemodialysis treat-ment was a recommendation ofrespondents in the ANNA VenousNeedle Dis lodgement Survey.

• The importance of monitoring ofthe patient’s access as a factoraffecting the risk of venous need ledislodgement was noted by VanWaeleghem et al. (2008), whorecommended that all pa tientsshould be monitored routinelyand that higher risk pa tientsrequire a higher level of observa-tion.

• Regarding staffing, Hurst (2011a)noted that venous needle dis-lodgement can occur any timeand anywhere, and can happenin “apparently routine treatmentsand with fully staffed units” (p. 149).

Patients on nocturnal and/oron home hemodialysis.• Hurst (2011b) has discussed

venous needle dislodgement pre-vention for the home hemodialy-sis population and suggested thatpatients should not rely solely onthe dialysis machine’s internalalarm. Hurst (2011b) urged in -creased “awareness and vigi-lance” by anyone who receivesdialysis and their caregivers.

• A number of ANNA VenousNeedle Dislodgement Surveyrespondents described using adevice that can detect blood lossto the environment to monitorthe venous needle access site ofpatients on nocturnal and homehemodialysis.

• Laird (2011) recommended thatpatients on nocturnal hemodialy-sis use an approved moisturealarm device during their hemo -dialysis treatments in addition todoing proper taping. Laird (2011)also advocated for patients keep-ing needle insertion sites andbloodlines visible during thehemodialysis procedure, not tap-ing bloodlines to an object, andnot disabling pressure alarms onthe dialysis machine.

Education and Awareness Venous needle dislodgement was

evidenced in the literature as a com-plication of hemodialysis with poten-tial for harm. Multiple factors wereidentified that can contribute to therisk of venous needle dislodgement.This reality demands a combinationof vigilance in monitoring and ongo-ing assessment of the patients, thedialysis machines, and other tech-nologies that nephrology nurses useand manage. Lascano and Anderson(2011) indicated that expectations ofthis high level of nursing care canonly be achieved when staff havebeen provided with education aboutthe importance of the “safety first”message as it relates to venous needledislodgement. Van Waeleghem et al.(2008) listed as their first practice rec-ommendation that patient care staff

and patients should be aware ofvenous needle dislodgement and itspossible consequences, and alsoadvocated for the education of pa -tients/family as a “fundamental” roleof the nephrology nurse.

Dialysis provider organizationsshould each develop evidence-basedpolicies and procedures that aredesigned to foster a safe and effectivetreatment environment for the pa -tient. To ensure safe care, it is essentialthat opportunities are provided forstaff to learn about these expectationsand be updated on venous needle dis-lodgement recommended practicesand technologies on a regular basis.

Practice Recommendations Based on the literature review

and the results of the ANNA VenousNeedle Dislodgement Survey, thereare important practice recommenda-tions that can be implemented to pre-vent venous needle dislodgement.

Prepare for Cannulation Of the Access Sites

Cleaning of the selected accesscannulation sites and allowing theareas to dry before cannulation servesa dual purpose. Removal of bacteriafrom the skin helps prevent accessinfection. Some disinfectant solutionsmust be allowed to dry to be effective.Allowing adequate time for the site todry before performing cannulationalso helps to prepare the skin surfaceso the tape will be better able to ad -here (Dinwiddie, 2008; Van Waeleghemet al., 2008).

Tape the Needles Securely Taping the needles securely is

key to preventing dislodgement(Lindley et al., 2010a; Mactier &Worth, 2007). The use of a chevrontaping configuration is indicated as amethod to secure the needle in theaccess vessel (Hurst, 2011b; Laird,2011; Van Waeleghem et al., 2008).General guidelines for securinghemodialysis access needles can befound in the ANNA Core Curriculum forNephrology Nursing (Amato et al.,2008). Mactier and Worth (2007)




reported on results from discussion ofprocedures for prevention of venousneedle dislodgement at a VenousNeedle Dislodgement Workshop thattook place in the United Kingdom in2006. This workshop was held after“…9 units had experienced 10episodes of fistula needle dislodge-ment in 6 months” (Mactier & Worth,2007, p. 9). While the authors indicat-ed that a specific method for securingaccess needles was not agreed upon atthe workshop, what was agreed uponwas that the dialysis units shoulddevelop their own clear guidelines forsecuring access needles (Mactier &Worth, 2007).

Replace Tape if RepositioningThe Needle

The tape should not just be loos-ened and then re-used after making aneedle adjustment. This tape mayhave lost its stickiness in the process,leaving the tape and the needle onlyloosely in contact with the skin. Freshtape should be applied to ensure thesecurity of the needle (Van Waeleghemet al., 2008).

Secure Bloodlines In their article on venous needle

dislodgement and how to minimizethe risk, Van Waeleghem et al. (2008)indicated that the bloodlines shouldbe looped loosely “…to allow move-ment of the patient and to preventbloodline pulling on the needles” (p164). Keeping the bloodlines taped/attached to the patient was suggestedas an intervention to help prevent anaccidental dislodgement in the simpleact of shifting position in a chair orrolling over in a bed. Bloodlinesshould be secured to the patient dur-ing treatment and not secured to anobject, such as the dialysis chair, blan-kets, or the bed rail (RPA, 2012a,2012b; Sandroni et al., 2008; VanWaeleghem et al., 2008).

Assure Access Visibility It is essential for the access to be

visible at all times (Gomez, 2011; RPA,2007). The April 18, 2008, MedicareFinal Rule for Conditions forCoverage statement includes “…the

access sites and line connectionsshould remain uncovered to allow staffto visually monitor these areas toensure patient safety” (U.S. De -partment of Health and HumanServices [(DHHS], & Centers forMedicare & Medicaid Services [CMS],2008, p. 20384). If there is venous nee-dle dislodgement, patients and staffwill be able to visualize the event andtake action immediately (Lindley et al.,2010b). Access checks should be partof regular rounds to be sure the accessneedles are in the vessels and securelytaped (Hurst, 2009; PennsylvaniaPatient Safety Authority, 2012).

Use of Dialysis Machine SafetyDevices

Hemodialysis machines havemethods of displaying the measure-ment of venous pressure during thedialysis treatment with a default rangefor alarm parameters. However, re -ported incidents of venous needle dis-lodgement without a machine alarmsounding are found in the literature(ECRI Institute, 1998, Mactier &Worth, 2007, Sandroni, 2005). Sev -eral auth ors have indicated that themachines involved in venous needledislodgements were tested after theincidents, only to find that the alarmswere functioning and responded cor-rectly within the default alarm limits(Sandroni, 2005; Sandroni, et al., 2008;Van Waeleghem et al., 2008). VanWaeleghem and colleagues (2008)concluded that even when the alarmlimits are set, the drop in venous pres-sure may be too small to activate thealarm, for example, when “…theaccess pressure is too low or becausethe needle is incompletely dislodgedor obstructed by material coveringthe needle sites” (p. 166). The venouspressure alarm safety feature cannotbe used as the only defense forvenous needle dislodgement. Vigil -ance and monitoring by staff areessential to provide safety from thispotential complication (VeteransHealth Administration, 2008)

Set the Venous PressureAlarm Limit

Some machines allow the user to

change the venous pressure alarmlimit range. It was indicated in the lit-erature that it could be helpful inmonitoring for venous needle dis-lodgement to set the limits in an asy -mmetrical pattern (such as -30/+70)with the lower limit of the venouspressure alarm as close as possible tothe current venous pressure. Thismay increase the possibility of themachine sounding an alarm if a ve -nous needle dislodgement occurs(Hurst, 2009; Mactier & Worth, 2007;Van Waeleghem et al., 2008).

Monitor Dialysis CathetersMonitoring catheter accesses

should be included in the nephrologynurses’ ongoing risk assessment ofvenous needle dislodgement. Cathe -ters have luer lock connections thatcan be a source of blood loss if theyare not connected tightly or if the luerlock is not threaded properly. Clipdevices have been used to help holdthe catheter ports and bloodlinestogether and to prevent disconnec-tion (Fields, 2010).

Use of Moisture MonitorsEnuresis pads, designed for

detecting moisture, have been des -cribed as having been used off-labelin an attempt to protect high-riskpatients from venous needle dislodge-ment; however, these pads have beenfound incapable of detecting verysmall volumes of moisture, makingthem ineffective as an early warningdevice for blood leaks (Hurst, 2009;Sandroni, 2005; Van Waeleghem etal., 2008).

Use of a Detection Device forBlood in the Environment

A number of researchers haverecommended the use an FDA-ap -proved device for blood in the envi-ronment with high-risk patients andfor patients doing home hemodialysis(Ahlmen et al., 2008; Cowperthwaite,Rivers, Sundstrom, & Hegbrant,2011; Fields, 2010; Hurst, 2009;Sandroni et al., 2008). An FDA-approved safety device, Redsense®, isspecifically designed for use on a dial-ysis access to detect blood loss at the



access site and sound an alarm if itoccurs. The device is connected by anoptic fiber to a sensor patch withadhesive that allows it to be placed onthe venous needle site (Ahlmen et al.,2008). The manufacturer’s literatureindicates this device is able to detectas little as 1 mL of blood (Takeuchi etal., 2010).

These practice recommendationsfor the prevention of venous needledislodgement are supported in theANNA Core Curriculum for NephrologyNursing, with recommendations tosecurely lock luer lock connections onall bloodlines and access lines; con-nect both arterial and venous blood-lines to access lines at the initiation ofthe hemodialysis treatment; andachieve complete stasis of access nee-dle sites before the patient leavesand/or clamp and cap central venouscatheters limbs (Dinwiddie, 2008).ANNA’s Nephrology Nursing Scopeand Standards of Practice (Gomez,2011) indicate that the nursing assess-ment should include the integrity ofthe extracorporeal circuit, connec-tions, and delivery system alarms,and monitoring of the patientthroughout the hemodialysis treat-ment. In addition, patient teachingrecommendations with considerationof the patient and family’s health liter-acy should include the patient’s rolein safe delivery of treatment, such asbeing aware of the effects of move-ment on the access and the need tokeep the access site and extracorpore-al connections uncovered. Thenephrology nursing process of carefor hemodialysis should include anindividualized approach to educatepatients and families regarding signsand symptoms that should bepromptly reported to patient care staff(Gomez, 2011).

Resources In response to the ANNA Ve -

nous Needle Dislodgement Surveyand the literature review, the ANNAVenous Needle Dislodgement SpecialProject Workgroup reviewed existingvenous needle dislodgement educa-tion materials with the goal of provid-

ing recommendations in easy-to-usetools to assist healthcare providersand patients to proactively minimizethe risk of venous needle dislodge-ment. A venous needle dislodgementrisk assessment tool for nephrologynurses from the European Dialysisand Transplant Nurses Association/European Renal Care Association(EDTNA/ERCA) (2010) was adaptedand revisions made based upon theANNA Venous Needle DislodgementSurvey recommended risk criteria. Aposter for patient care staff educationfrom the EDTNA/ERCA work wasadapted and revised based uponnephrology nurses’ indications of rec-ommended practices to reduce therisks for venous needle dislodgement.In addition, a patient education toolwas developed to assist in educationof patients/family on how they canhelp to minimize their risk of venousneedle dislodgement during hemo -dialysis.

The tools adapted and revised bythe ANNA Venous Needle Dislodge -ment Special Project Workgroup aredesigned to present recommendedpractices as supported by current lit-erature and as reported in nurses’experiences with venous needle dis-lodgement obtained from the ANNAVenous Needle Dislodgement Survey.These tools have been provided inthe format of a pocket card, a poster,and a one-page handout.

The pocket card is entitled“Assessment of the Risk for a SeriousVenous Needle Dislodgement Inci -dent” (see Figure 1). The literaturesupports the need for assessing thepatient for potential risk of venousneedle dislodgement as key to pre-venting its occurrence (Lindley, 2005;McCabe et al., 2009). The “Assess -ment of the Risk” tool is designed toassist the nephrology nurse in per-forming a four-level assessment ofpatient risk and to provide recom-mendations for interventions that cor-relate with each of four identifiedpatient levels of risk.

The poster, Venous Needle Dis -lodgement (VND): How to Minimize theRisks, was designed to provide prac-tice recommendations for patient care

staff, patients, and other caregivers(see Figure 2). The recommendationsstart with the need to be aware of riskfactors for venous needle dislodge-ment and the consequences of venousneedle dislodgement. Recommen -dations progress from preparing theneedle sites to securely taping theneedles, securing and positioning thebloodlines, maintaining visibility, andmonitoring the access during treat-ment. The tool concludes with venouspressure monitoring recommenda-tions and technologic advancementsof devices intended to detect bloodloss to the environment from dis-lodgement of the venous needle.

Dialysis staff who have an under-standing of the risks of venous needledislodgement and strategies to reducethese risks can discuss the risks andstrategies with patients, families, andother healthcare providers. TheANNA Venous Needle DislodgementSpecial Project Workgroup developedan education tool, Help Us Keep YouSafe!, that can be used as a handout aswell as a poster in the dialysis unit toassist in initiating this important discus-sion (see Figure 3). This patient educa-tion resource was designed as a simpleand visual message for the educationof patients and families of their roles inhelping the patient care staff keeppatients safe during treatment.

All three of these resources weredesigned to serve as reminders ofhow patients can be at risk for venousneedle dislodgement and to providerecommendations for how to mini-mize the risk of venous needle dis-lodgement.

ConclusionA literature review and the results

of the ANNA Venous Needle Dis -lodgement Survey validate venousneedle dislodgement as a potentialcomplication of hemodialysis thera-py. Patient care staff and patientawareness of the risk have been iden-tified in the literature review, and theANNA Venous Needle DislodgementSurvey is an important factor in theprevention of venous needle dis-lodgement.




Figure 1Pocket Card: Assessment of the Risk for a Serious Venous Needle Dislodgement Incident



Figure 2Poster from the ANNA Venous Needle Dislodgement Special Project Workgroup




As a result, the ANNA VenousNeedle Dislodgement Special ProjectWorkgroup developed a tool contain-ing recommendations for the assess-ment of the risk of venous needle dis-lodgement and an education resourcewith proactive recommendations thatcan be utilized by all patient care staffcollaboratively to minimize the risk ofvenous needle dislodgement. Thepatient education resource can be ofvalue for the education and engage-

ment of patients and family membersto minimize the risks of venous nee-dle dislodgement in hemodialysis.

Nephrology nurses must lead theway in their essential roles of workingcollaboratively with all patient carestaff, patients, and families to reducethe significant and potentially fatalcomplication that can occur from lossof blood due to venous needle dis-lodgement.

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ECRI Institute. (1998). Undetected venousline needle dislodgement duringhemodialysis. Medical device safetyreports (online). Retrieved fromhttp://www.mdsr.ecri.org/summa-ry/detail.aspx?doc_id=8300

European Dialysis and Transplant NursesAssociation/European Renal CareAssociation (EDTNA/ERCA) (2010,September 20). Venous needle dislodge-ment (VND) recommendations for renalnurses on how to minimize the risks.Venous Needle Dislodgement Work -group. Poster session presented at the39th Annual Meeting of EDTNA/ERCA, Dublin, Ireland.

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Figure 3Patient Education Resource: Help Us Keep You Safe!



Hurst, J. (2011a). Venous needle dislodge-ment: A universal concern. EuropeanNephrology, 5(2), 148-151. Retrievedfrom http://www.touchbriefings.com/ebooks/A1uupa/euneph52/

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Van Waeleghem, J.P., Chamney, M.,Lindley, E.J., Olausson, S., &Pancirova, J. (2008). Venous needledislodgment: How to minimize therisks. Journal of Renal Care, 34(4), 163-168.

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Additional ReadingLascano, M.E. (2011). Keeping kidney pa -

tients safe: Venous needle dislodgement.Retrieved from http://www.kidney-pateintsafety.org

Nephrology Nursing Journal Editorial Board Statements of Disclosure

In accordance with ANCC governing rules Nephrology Nursing Journal Editorial Board statements of disclosureare published with each CNE offering. The statements of disclosure for this offering are published below.

Deborah H. Brooks, MSN, APN-BC, CNN-NP, disclosed that she is on the Consultant Presenter Bureau and theAdvisory Board for Affymax, Inc.

Paula Dutka, MSN, RN, CNN, disclosed that she has received grant/research support from Keryx, Amgen,Rockwell, Fibrogen, Dynovox, and Otsuka; and she is on the Consultant and Presenter Bureau and theNephrology Nurse Advisory Board for Affymax/Takeda.

Patricia B. McCarley, MSN, RN, ACNPc, CNN, disclosed that she is on the Consultant Presenter Bureau forAmgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche andis the recipient of unrestricted educational grants from OrthoBiotech and Roche.


venous needle dislodgement in patients on hemodialysis

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