Tubing misconnections in critical set up is often a grave error which needs to be addressed well with policies and standard operating procedures. A good understanding of the problem by the team will go a long way in preventing this mishap to ever happen in your team.
2. LookLook āā CheckCheck āā ConnectConnect
ā¢ Misconnecting medical device tubing can lead to serious patient harm
or death. The FDA is working with standards organizations, the Joint
Commission, and professional groups to support the correct use of
device connectors to reduce the chance of tubing misconnections
ā¢ Ensure all clinicians and providers are trained in advance of about
connectors to avoid any problems with misconnections
ā¢ Advise all staff to not modify or adapt the device or its connector
outside of its intended use, in order to prevent misconnections.
3. Case studyCase study
ā¢ An infant in the pediatric intensive care unit had both a
feeding tube and a trach tube
ā¢ The feeding tube was inadvertently placed in the trach tube
and milk was delivered into the infantās lungs
ā¢ The infant died
ā¢ THE JOINT COMMISSION2
SAFETY TIP: Always trace a
tube or catheter from the patient to the point of origin
before connecting any new device or infusion
5. Case studyCase study
ā¢ An anesthetist and a midwife mistakenly connected an
epidural set to the patientās IV tubing
ā¢ The epidural medicine was delivered to the IV
ā¢ The patient died
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: For certain
high-risk catheters (e.g., epidural, intra-thecal, arterial),
label the catheter and do not use catheters that have
injection ports
ā¢
7. Case studyCase study
ā¢ A child in a pediatric intensive care unit had both an IV
line and a trach tube
ā¢ The IV tubing was mistakenly connected to the trach cuff
port
ā¢ The IV fluid over-expanded the trach cuff to the point of
breaking and continuous IV fluids entered the childās lungs
ā¢ The child died
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Emphasize
the risk of tubing misconnections in orientation and
training
ā¢
8. IV tubing erroneously connected to trachIV tubing erroneously connected to trach
cuffcuff
9. Case studyCase study
ā¢ During a nebulizer treatment, the patientās oxygen tubing
fell off the nebulizer and the patientās IV tubing was
inadvertently attached to the nebulizer
ā¢ When the patient inhaled, a moderate amount of IV fluids
was aspirated into the patientās lungs
ā¢ The misconnection was identified by the respiratory
therapist and the patient survived
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Do not
purchase non-intravenous equipment that is equipped with
connectors that can physically mate or attach with a female
Luer IV line connector
10. IV tubing erroneously connected toIV tubing erroneously connected to
nebulizernebulizer
11. Case studyCase study
ā¢ A patientās oxygen tubing became disconnected from his
nebulizer and was accidentally reattached to his IV tubing
Y-site by a staff member who was completing a double
shift
ā¢ The patient died from an air embolism, even though the
connection was broken within seconds
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Identify
and manage conditions and practices that may contribute to
health care worker fatigue, and take appropriate action
12. Oxygen tubing erroneously connected to aOxygen tubing erroneously connected to a
needleless IV portneedleless IV port
13. Case studyCase study
ā¢ An ER patient had an IV heparin lock but no IV fluids had been
started. The patient also had a noninvasive automatic BP cuff placed
for continuous monitoring
ā¢ The BP cuff tubing was disconnected when the patient went to the
bathroom
ā¢ When she returned, her spouse mistakenly connected the BP cuff
tubing to the IV catheter and approximately 15 mL of air was delivered
to the IV catheter
ā¢ The patient died from a fatal air embolus, despite resuscitation efforts
ā¢ POTENTIAL FOR HARM: High
ā¢ Inform non-clinical staff, patients and their families that they must get
help from clinical staff whenever there is a real or perceived need to
connect or disconnect devices or infusions
ā¢
14. Blood pressure tubing erroneouslyBlood pressure tubing erroneously
connected to IV catheterconnected to IV catheter
15. Case studyCase study
ā¢ A nurseās aide inadvertently connected a patientās IV tubing to the
nasal oxygen cannula upon transfer to the step down unit
ā¢ The misconnection was not noted until four hours later, when the
patient complained of chest tightness and difficulty breathing
ā¢ The patient was treated for congestive heart failure and survived
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Recheck connections
and trace all patient tubes and catheters to their sources upon the
patientās arrival in a new setting or service as part of the handoff
process. Standardize this āline reconciliationā process.
ā¢
16. IV tubing erroneously connected to nasalIV tubing erroneously connected to nasal
cannulacannula
17. Case studyCase study
ā¢ The patient had both a central line with three ports and a trach tube
ā¢ Medicine intended for the central line was inadvertently injected into
the trach cuff
ā¢ The trach cuff was damaged and the medicine entered the patientās
lungs
ā¢ A new trach tube was inserted and the patient survived
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Always trace a tube or
catheter from the patient to the point of origin before connecting any
new device or infusion
ā¢
19. Case studyCase study
ā¢ A patientās feeding tube was inadvertently connected to the
instillation port on the ventilator in-line suction catheter
ā¢ Tube feeding was delivered into the patientās lungs
ā¢ The patient died
ā¢ POTENTIAL FOR HARM: High
ā¢ Emphasize the risk of tubing misconnections in orientation
and training
ā¢
21. Case studyCase study
ā¢ A patient admitted for stroke had a pulsatile anti-embolism stocking (PAS) on
the left lower extremity and an IV heparin lock in the right ankle
ā¢ The patient was alert and oriented on admission but shortly after was found
unresponsive and cyanotic
ā¢ The PAS pump tubing was found connected to the IV heparin lock in the
patientās right ankle
ā¢ The patient died of a massive air embolus
ā¢ POTENTIAL FOR HARM: High
ā¢ THE JOINT COMMISSION SAFETY TIP: Manufacturers should
implement ādesigned incompatibilityā as appropriate, to prevent dangerous
misconnections of tubes and catheters
ā¢
23. CASE STUDYCASE STUDY
ā¢ A child had both a gastric feeding tube for nutrition and an IV for medicine
and hydration
ā¢ When the childās gown was changed, a family member inadvertently attached
the IV tubing to the gastric feeding tube
ā¢ The medicine was delivered through the feeding tube into the stomach
ā¢ There was no patient harm since the event was noted in a timely manner
ā¢ POTENTIAL FOR HARM: Moderate
ā¢ THE JOINT COMMISSION SAFETY TIP: Inform non-clinical staff,
patients and their families that they must get help from clinical staff whenever
there is a real or perceived need to connect or disconnect devices or infusions
ā¢
25. Ensure that health-care organizations have systems and
procedures in place which:
ā¢ Emphasize to non-clinical staff, patients, and families that devices
should never be connected or disconnected by them. Help should
always be requested from clinical staff.
ā¢ Require the labeling of high-risk catheters (e.g. arterial, epidural,
intrathecal).
ā¢ Use of catheters with injection ports for these applications is to be
avoided.
ā¢ Require that caregivers trace all lines from their origin to the
connection port to verify attachments before making any connections
or reconnections, or administering medications, solutions, or other
products.
26. Ensure that health-care organizations have systems and
procedures in place which:
ā¢ Include a standardized line reconciliation process as part of handover
communications.
ā¢ This should involve rechecking tubing connections and tracing all
patient tubes and catheters to their sources upon the patientās arrival in
a new setting or service and at staff shift changes.
ā¢ Bar the use of standard Luer-connection syringes to administer oral
medications or enteric feedings.
ā¢ Provide for acceptance testing and risk assessment (failure mode and
effects analysis, etc.) to identify the potential for misconnections when
purchasing new catheters and tubing.