Case Studies regarding tubing and luer Misconnections

Published

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/Safety/AlertsandNotices/TubingandLuerMisconnections/ucm313275.htm

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Thanks :up:

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Your welcome. lets not make the same mistake. :D horrible stuff I feel bad esp for the infant, the nurse accidently connect the iv line on the trach :(

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Thread moved for better response/exposure. :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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/MedicalDevices/Safety/AlertsandNotices/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

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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.

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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.

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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.

Note: to get full impact of this message, it should display in Comic Sans, green. Thank you.

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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.

Note: to get full impact of this message, it should display in Comic Sans, green. Thank you.

I'm confused. You mean she took NG drainage and put it into his IV? Is that compatible with life?

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Just leaves me shaking my head!

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Specializes in Trauma/Tele/Surgery/SICU.

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.

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Specializes in Med/surg, Quality & Risk.

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.

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