JCAHO Alert: Tubing misconnections—a persistent and potentially deadly occurrence

Once again, I think the answer is more nurses. I can't help but think that some of these less flagrant errors can be attributed to too many patients and not enough time.

Adding more staff can help but it won't solve the entire problem. As I thought about this thread I realized that many of these may have not been done by the nurse.

How often could a family member mistakenly hook a loose line up because "It must go somewhere."?

Also, aides and techs might be responsible for some of the connections.

I showed this article to my wife who has been a nurse for 27 years. She didn't doubt that these things could happen. One time in a LTC facility one of her LPNs inserted a vaginal suppository into the patient's belly button.

Good lord, I can't even imagine how some of those examples even happened! I mean, how exactly does one not notice that they are attaching an IV tubing to a trach, or a tube feed to a foley/central line? Are the people who do this graduates of 2 week distance education nursing courses? Yikes!

so sad to know that there will always be stupid things happening in the nursing practice.how such things occured were really irrational,lack of experience,practice,familliarization of works and equipments..etc???? come on.we are dealing with HUMAN's life....its not a simple paper works, once you done it wrong you could just scrampled it and throw.

Concerning the misconnections. Questions, arise on the nature of the unit in which this happened. Understaffing and overworked, Rn's are tired and stressed. The shame is that all this happened in the first place. I am not convinced that it happened under properly skilled alert RNs. The hospital, unit manager or staffing coordinator, I think may bear some responsibility.

Obviously many issues at play here. Fatigue, understaffing, high patient acuity, etc.

Regarding the tube feeding into the IV line... our GI docs started using a new PEG tube that had a luer lock and needed a feeding line that looked very much like an IV line. Scared the crap out of me, as I envisioned just this scenario. I labeled the hell out of it. People laughed and thought I was being paranoid, but in 23 years I've seen some stupid things.

As a RN ONLY YOU are responsible for your practise. You have people's lives in your hands. By god if you are too tired, overworked, intoxicated on drugs or alcohol, or are in too much of a hurry then you better not be giving medications especially through central lines. The hospital, manager, etc... are not responsible for that life, you are. That is why we are taught the 5 rights and that is why we MUST practise it.

In our ICU we had a Nurse give a bolus of K+! Thankfully nothing happend to the pt.....She hooked it up DIRECTLY to the primary tubing! NO PUMP!

I would have been the first to agree that it's stupidity/impairment UNTIL it nearly happened to me. In our NICU it's not uncommon for someone to use 60" microbore luer-lock med tubing instead of an enteral feed extension set because the former is usually easier to find. A 6Fr NGT is just the right size for that microbore tubing. So yeah, I once ALMOST hooked up a breast milk feed to an IV while on orientation. I caught it, but I almost didn't. And I was neither stupid nor high. Never change a feed syringe and a med syringe at the same time, kiddies.

Now I'm the tubing Nazi. I go a little crazy looking for those *&&^((* enteral extension sets that actually don't fit as well and have to be taped on to go with our PEG fittings. Oh, and even those have luer-locks at the syringe end. We don't even stock non-luer syringes on my floor. Oh, and JCAHO is coming next week. This should be fun...