Case Studies regarding tubing and luer Misconnections

  1. 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. http://www.fda.gov/MedicalDevices/Sa.../ucm313275.htm
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  2. 15 Comments

  3. by   rn1mid
    Thanks
  4. by   nurse671
    Your welcome. lets not make the same mistake. horrible stuff I feel bad esp for the infant, the nurse accidently connect the iv line on the trach
  5. by   Esme12
    Thread moved for better response/exposure.
  6. by   Esme12
    After looking at the FDA alert.......I have to shake my head and wonder how and why........
    These case studies are based on reports of adverse events received by the FDA. The potential
    for harm designations: High, Medium and Low refer to the severity of patient harm that could result from the depicted type of misconnection.

    These case studies are also available in high quality printable PDF format http://www.fda.gov/downloads/Medical.../UCM134873.pdf .
    Picture examples of these real reported mistakes......

    Feeding Tube Erroneously Connected to Trach Tube
    Epidural tubing erroneously connected to IV tubing
    IV tubing erroneously connected to trach cuff
    IV tubing erroneously connected to nebulizer
    Oxygen tubing erroneously connected to a needleless IV port
    Blood pressure tubing erroneously connected to IV catheter
    IV tubing erroneously connected to nasal cannula
    Syringe erroneously connected to trach cuff
    Enteral feeding tube erroneously connected to ventilator in-line suction catheter
    Pulsatile anti-embolism stocking erroneously connected to IV heparin lock
    IV tubing erroneously connected to enteral feeding tube
    Foley catheter erroneously connected to NG tube
  7. by   Mulan
    I remember one time a patient went down to xray and after coming back was found with a feeding tube inserted into a foley port (instead of a peg tube). Don't know if it was done in xray or if it was done back on the floor or somewhere in between.
  8. by   Mulan
    Some of those don't even sound believable, like someone made them up.

    A SCD connected to a heparin lock?

    I would think the IV fluid going into the nasal cannula would cause someone to complain of fluid dripping from their nose to their throat long before they would complain of chest tightness and difficulty breathing.
  9. by   nurseprnRN
    Holy moly.

    Of course, my favorite, that I actually saw done, was a patient transferred to our SICU from the floor. it was common to have orders for fluid replacement for large amounts of NG drainage, like "replace NG drainage cc for cc with NS q4h," or some such. Well, this poor SOB had a nurse with a brain fart and she took the fluid out of the NG suction cannister, measured it....and put it in his volutrol. Can you say "Acidosis"? Yeah, IV fluid with a pH of about 2 will do that to ya.

    I also saw a TPN attached to an epidural cath. Fortunately it didn't run for toffee.


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  10. by   Mulan
    Quote from GrnTea
    Holy moly.

    Of course, my favorite, that I actually saw done, was a patient transferred to our SICU from the floor. it was common to have orders for fluid replacement for large amounts of NG drainage, like "replace NG drainage cc for cc with NS q4h," or some such. Well, this poor SOB had a nurse with a brain fart and she took the fluid out of the NG suction cannister, measured it....and put it in his volutrol. Can you say "Acidosis"? Yeah, IV fluid with a pH of about 2 will do that to ya.

    I also saw a TPN attached to an epidural cath. Fortunately it didn't run for toffee.



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    I'm confused. You mean she took NG drainage and put it into his IV? Is that compatible with life?
  11. by   Daisy_08
    Just leaves me shaking my head!
  12. by   Sugarcoma
    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.
  13. by   redhead_NURSE98!
    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.
  14. by   nurseprnRN
    @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.

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