Includes failures of dedicated patient cannulation or vascular-access controls, including appropriate insertion, replacement, procedural requirements, clinical guidance, policy alignment and staff adherence, where the failure concerns safe cannulation itself.
What is not included
Excludes generic clinical-procedure, staffing, training or documentation deficiencies that are not specifically tied to patient cannulation or vascular access.
Excludes failures involving administration, monitoring or treatment after vascular access has been safely established, unless the assertion directly concerns the cannulation or access procedure.
Excludes unrelated equipment or emergency-response failures, including incorrect defibrillator use, where no cannulation or vascular-access control is identified.
Excludes non-patient vascular or non-clinical access processes.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care2
Academy of Medical Royal Colleges1
Association Of Anaesthetists (Great Britain & Ireland)1
British Association of Perinatal Medicine1
National Infusion and Vascular Access Society1
National Institute for Health and Care Excellence1
NHS England1
Royal College of Anaesthetists1
Royal Sussex County Hospital1
University Hospitals Sussex NHS Foundation Trust1
Executive non-departmental public body2
Health professional body2
Ministerial department2
Healthcare site1
NHS trust1
Registered charity1
Reports and published responses 4 reports
See individual reports that have raised this concern, and the actions taken in response
West Yorkshire (Western)
Concerns raised1
Absence of a national policy on the placement of central venous catheters
Linked responses
Association Of Anaesthetists (Great Britain & Ireland)
Department of Health and Social Care
National Institute for Health and Care Excellence
NIVAS (National Infusion and Vascular Access Society
Royal College of Anaesthetists
The Intensive Care Society
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists and The Intensive Care Society
Update Safe Vascular Access guidance to include more explicit recommendations for checking central venous catheter placement.
NIVAS (National Infusion and Vascular Access Society
Publish guidelines on real-time ultrasound guidance and recognition and management of inadvertent arterial puncture or cannulation.
National Institute for Health and Care Excellence
Publish guidance recommending ultrasound locating devices for central venous catheter placement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
National Institute for Health and Care Excellence
Further NICE guidance on central venous catheter placement is not considered necessary because existing national recommendations and standard requirements are sufficient.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Existing national standards and guidance are sufficient to inform local standards for central venous catheter placement.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
No further departmental action is considered necessary because the treating clinician departed from existing national recommendations, guidelines and Trust policy.
No action considered necessaryThe respondent said that no further action was needed.
Surrey
Concerns raised3
Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance
Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance
Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Association of Perinatal Medicine
National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
British Association of Perinatal Medicine
Publish an evidence-based Framework for Practice on neonatal central venous catheter use to reduce complications and support early recognition of extravasation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
National Institute for Health and Care Excellence
NICE considers no direct action necessary at present, while logging the concerns for consideration during the next NG154 update.
No action considered necessaryThe respondent said that no further action was needed.
National Institute for Health and Care Excellence
Education and training of healthcare professionals is assigned to relevant professional bodies, including the Royal Colleges, GMC and Health Education England.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
British Association of Perinatal Medicine
The suggested amendment requiring NHS Trusts to ensure clinician familiarity with the current BAPM Framework is unnecessary and cannot be guaranteed to prevent recurrence.
No action considered necessaryThe respondent said that no further action was needed.
National Institute for Health and Care Excellence
The BAPM framework is considered sufficient to contain information on UVC insertion and associated risks, so NICE will not produce specific recommendations.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Plymouth, Torbay and South Devon
Concerns raised1
Need for improvement in central venous line insertion processes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Faculty of Intensive Care Medicine
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Faculty of Intensive Care Medicine
Mandating a higher number of line-insertion procedures would not prevent this complication.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Brighton and Hove
Concerns raised1
Failure to cannulate patients appropriately
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.