Published
issue 36 - april 3, 2006
tubing misconnections--a persistent and potentially deadly occurrence
tubing and catheter misconnection errors are an important and under-reported problem in health care organizations. in addition, these errors are often caught and corrected before any injury to the patient occurs. given the reality of and potential for life threatening consequences, increased awareness and analysis of these errors--including averted errors--can lead to dramatic improvement in patient safety.
to date, nine cases involving tubing misconnections have been reported to the joint commission's sentinel event database. these resulted in eight deaths and one instance of permanent loss of function, and affected seven adults and two infants. reports in the media and to organizations such as ecri, the food and drug administration (fda), the institute for safe medication practices (ismp), and united states pharmacopeia (usp) indicate that misconnection errors occur with significant frequency and, in a number of instances, lead to deadly consequences.
types of misconnections
the types of tubes and catheters involved in the cases reported to the joint commission included central intravenous catheters, peripheral intravenous catheters, nasogastric feeding tubes, percutaneous enteric feeding tubes, peritoneal dialysis catheters, tracheostomy cuff inflation tubes, and automatic blood pressure cuff insufflation tubes. the specific misconnections involved an enteric tube feeding into an intravenous catheter (4 cases); injection of barium sulfate (gi contrast medium) into a central venous catheter (1 case); an enteric tube feeding into a peritoneal dialysis catheter (1 case); a blood pressure insufflator tube connected to an intravenous catheter (2 cases); and injection of intravenous fluid into a tracheostomy cuff inflation tube (1 case).
a review by usp of more than 300 cases reported to its databases found misconnection errors involving the following:
many of the misconnection cases involved luer connectors--small devices used in the connection of many medical components and accessories. there are two types of luer connectors--slips and locks. a luer slip connector consist of a tapered "male" fitting that slips into a wider "female" fitting to create a secure connection. the luer lock connector has a threaded collar on the "male" fitting and a flange on the "female" fitting that screw together to create a more secure connection. examples of misconnections involving luer connectors include the following:
root causes identified
the basic lesson from these cases is that if it can happen, it will happen. luer connectors are implicated in or contribute to many of these errors because they enable functionally dissimilar tubes or catheters to be connected. other identified causes include the routine use of tubes or catheters for unintended purposes, such as using iv extension tubing for epidurals, irrigation, drains, and central lines, or to extend enteric feeding tubes; and the positioning of functionally dissimilar tubes used in patient care in close proximity to one another. in the cases reported to the sentinel event database, contributing factors included movement of the patient from one setting or service to another, and staff fatigue associated with working consecutive shifts.
risk reduction strategies
there are currently no published standards that specifically restrict the use of luer connectors to certain medical devices. consequently, a broad range of medical devices, which have different functions and access the body through different routes, are often outfitted with luer fittings that can be easily misconnected. organizations in europe and the u.s. are now developing standards to restrict the types of devices that use luer fittings in an attempt to mitigate misconnection hazards. according to jim keller, vice president, health technology evaluation and safety for ecri, and stephanie joseph, project engineer for ecri, the solution to reducing--even eliminating--misconnection errors lies in both engineering controls respecting how products and devices are designed ("incompatibility by design"), and in re-engineering work practices.
"a well-designed device should prevent misconnections and should prompt the user to take the correct action," explains joseph, author of a guidance article published in the march 2006 issue of ecri's health devices journal. as a first step in prevention, joseph urges hospitals to avoid buying non-intravenous equipment (such as nebulizers, nibp devices, and enteral feeding sets) that can mate with the luer connectors on patient iv lines. in addition, joseph emphasizes that the single most important work practice solution for clinicians is to trace all lines back to their origin before connecting or disconnecting any devices or infusions.
other solutions include specific education and training regarding this problem for all clinicians and having practitioners take simple precautions such as turning on the light in a darkened room before connecting or reconnecting tubes or devices. the risk of waking a sleeping patient is minimal by comparison. errors have also occurred when patients or family members attempt to disconnect and reconnect equipment themselves. staff should emphasize to all patients the importance of contacting a clinical staff member for assistance when there is an identified need to disconnect or reconnect devices.
other approaches to reducing the risk of misconnections that have been identified also have significant potential for unintended consequences. these include:
joint commission recommendations
the joint commission offers the following recommendations and strategies to health care organizations to reduce tubing misconnection errors:
in addition, the joint commission urges product manufacturers to implement "designed incompatibility," as appropriate, to prevent dangerous misconnections of tubes and catheters.
resources
ismp medication safety alert, june 17, 2004, www.ismp.org/msaarticles/tubingprint.htm
nursing 2005, 35 (9), september 2005, pg. 73, by melissa eakle, r.n., mba, msn; beverly albrecht gallauresi, r.n., b.s., mph; and audrey morrison, r.n.
fda patient safety news, show #31, september 2004; show #20, october 2003; show #46, december 2005
"fatal air embolism caused by the misconnection of a medical device hoses to needleless luer ports on iv administration sets" [hazard report], ecri, health devices, june 2004; 33(6):223-5
"misconnected flowmeter leads to two deaths" [special report], ecri, health devices alerts, january 25, 2003
"preventing misconnections of lines and cables," ecri, health devices, march 2006; 35(3):81-95
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other jcaho alerts located:sentinel event alert
Gosh- this may sound mean but you have to be just plain STUPID or BLIND to connect a NIBP cuff or SCD to an IV or tube feeding to a CBI and so on. I mean, you would have to be paying NO ATTENTION whatsoever. In that case, maybe these people shouldn't be in nursing. :uhoh21:
i have to completely agree. i can't fathom a registered professional nurse hooking up a ngt feed to an iv line??!!!
completely unacceptable and pure stupidity!!!!!!!:angryfire
are these the kind of nurses they're putting through school in these 12 month fastrack programs??? in 20 years, i have never heard of such stupidity!!!!
I liked what the article had to say about prevention, though. Turn on a light, follow lines to point of origin, label things, etc. Oh yeah. And don't carry PO liquid meds to the bedside in a syringe even if you measured it in a syringe. There was a local case I heard of where someone put Milk of Mag in a central line doing that; gives me shivers to think of it. I've gotten pretty OCD about my central lines: I line up syringes on the counter for the drugs and put needles by them. Then I look at it and put flushes before each drug syringe, in between them and after, then another syringe with needle at the end for heparin flush. THEN label 'em as I draw 'em up. I never label the salines unless I think I'm not giving the drugs right then. But it can get downright complicated if you expect to push drugs then draw blood, then change one or all of the needleless valves... I'd hate to have been the nurse who said, ok while I'm at it let's give him some MOM and then boom. Dead patient, bybye license. It would have been well worth it to take some extra time to squirt the MoM into a paper cup.
i'm speechless! someone put milk of mag into a cvp??????? what the hell did they think they were pushing???? it's white for crying out loud!!!!! :uhoh3:
i wonder if these same idiots would go home and pour oj into their milk???? just stupid! plain stupid!
Gosh- this may sound mean but you have to be just plain STUPID or BLIND to connect a NIBP cuff or SCD to an IV or tube feeding to a CBI and so on. I mean, you would have to be paying NO ATTENTION whatsoever. In that case, maybe these people shouldn't be in nursing. :uhoh21:
Agreed! Whether it's fatigue, drugs, or lack of grey matter, these folks are not firing on all cylinders. I sure would not want them to be my nurse or taking care of anyone I love.
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 lady partsl 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.
Roy Fokker, BSN, RN
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