Tubing misconnections
Misconnection of tubing used to link patients to medical devices or medical devices to each other, have the potential to result in serious injury or death. and are believed to be under-reported. Although errors involving various types of tubing and catheters have been reported for over 20 years, there has been a recent increase in awareness of this issue and a call for solutions from governmental agencies, professional organizations, and patient safety groups. In April 2006, the Joint Commission issued a Sentinel Event Alert (.pdf) (44 KB) entitled "Tubing misconnections—a persistent and potentially deadly occurrence" that offered strategies for healthcare organizations to reduce risk and called upon manufacturers to redesign products to prevent misconnections.
Medical devices used in hospitals must have the ability to connect to related tubing and accessories –the standard "luer" connector makes this possible. However, because the luer connector is a standard size and is used on such a broad range of medical devices and products with totally different functions, the risk for tubing misconnections is great.
A patient, for example, may be connected to several devices used to administer fluids through a vein; deliver feedings via a tube to the stomach; monitor blood pressure; and administer oxygen via mask or cannula. This collection of devices, all of which may include luer connectors, poses a risk of tubing misconnection especially in a busy clinical environment where stress, fatigue and distractions are common.
Examples of tubing misconnections that may lead to severe illness or death include:
- Liquid feedings or formula intended for a feeding tube or nasogastric (NG) tube into the stomach is accidentally connected to an intravenous (IV) line –delivers liquid feeding into the bloodstream.
- A non-invasive blood pressure insufflation tube is accidentally connected to IV line--delivers air under pressure into the bloodstream causing an air embolism.
- IV fluids are accidentally connected to the inflation cuff on a breathing tube (tracheostomy or endotracheal tube) --delivers a large volume of fluid to a fixed volume device designed to be filled with air (the cuff), causing it to burst with fluid leaking into the airway resulting in airway obstruction.
- NG or tube feedings accidentally connected to a peritoneal dialysis catheter—delivers formula intended for the stomach to the abdominal (peritoneal) cavity.
Governmental, professional, and trade organizations along with medical device and product manufacturers are collaborating to develop standards that limit the use of luer fittings to specific devices and design other connectors that are incompatible with luer connections for the remaining devices. Experts agree that the best solution to prevent tubing misconnections is to change the design of the connectors so only devices that should be connected are able to be connected and those devices that should not be connected are incompatible. This design incompatibility would make it easy to make the correct connection and difficult or impossible to make the "wrong" connection or a tubing misconnection.
Resources
Additional information and resources are provided, including the Joint Commission Sentinel Event Alert, a case study on preventing enteral - IV misconnections in the neonate, and a list of Premier contracted suppliers offering products to reduce the risk of tubing misconnections.