Case Studies regarding tubing and luer Misconnections - page 2

According to US Food and Drug Association ACT (Assess Communicate Trace) is a way to preventing tubing misconnections. Check out the Case Studies that they have, very interesting.... Read More

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    On my first job during nursing orientation we had a presentation on this and a couple of the case studies I remember like the baby with the feeding hooked into the trach. Even though I was convinced my first med-surg instructor was satan incarnate, she drilled it into our heads: You better know where EVERYTHING that is connected to your patient is going, why it is there and check it frequently! If you didn't do this you failed clinical. I thank that woman everyday.
    Not_A_Hat_Person and GrnTea like this.

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    I come back to my pts who have been up with physical therapy with crap disconnected, or crap connected where it shouldn't be. A patient told me, "yeah the doctor came in and got mad and broke that off because it was in the wrong place." PT had hooked up the NG suction to the sump part of the NG tube instead of the main, and had the main capped off, and the doctor couldn't pull it apart and fix it so he broke it off. Not a huge deal but not right either. Jeez, just leave it alone if you can't figure it out.

    I hated to see the one about the guy who re-connected a b/p cuff to an IV line and killed his wife.
    lindarn, GrnTea, and Sugarcoma like this.
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    @Mulan Yep, that's it exactly. Fortunately we had a really good ICU so he did not die, but he did give it a good shot.

    Note: to get full impact of this message, it should display in Comic Sans, green. Thank you.
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    All I can say is WOW. Very scary that some health professionals think this connects to that, but then again we all make mistakes. Thanks for posting... I have forwarded this to my classmates.
    nurse671 and lindarn like this.
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    When I worked in hepatobillary I had a patient with pancreatitis that was so bad that they had to operate to remove the damaged part of her pancreas.

    Apparently it was like wet gravel inside so it was decided to put her on long tern abdominal washout. She also had a PEJ feed going as well. It was ground into all the staff what line was for feed what was for saline (as they were identical tubes) and which was output (the Foley catheter).

    Anyhow, we had a float nurse on one day. This patient was never given to float staff for obvious reason. The idiot of a charge nurse who has been charge for 10 years decided to allocate the float this pt.

    The inevitable happened and I walked onto the pm shift to a drainage bag of ensure instead of gravel. Thankfully a quick change of lines and more washout fixed the issue but OMG!
    lindarn likes this.
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    Some of those just don't make sense.. The connections wouldn't seem tight.. I guess we all make mistakes.. This was a good reminder to double check ALL conections.
    nurse671 and lindarn like this.


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