Patients being treated at healthcare facilities may have multiple tubing connections designed to provide different medical treatment products. Disaster can occur when tubing is connected incorrectly. The most well-studied example is when enteral feeding solutions are accidentally directed into intravenous (IV) lines. The Joint Commission (TJC) found 116 case studies, including 21 that resulted in deaths, due to this type of misconnection, discussed in a recent Sentinel Event Alert. In 2006, this happened to a pregnant woman, resulting in the death of both her and her fetus. (See our previous blog on this topic.)
Issues involving tubing misconnections have been reported since the 1970s and are not limited to feeding tube/ IV mix-ups. Many types of tubing for medical product delivery are susceptible to misconnection due to the use of luer connectors, which allow a high degree of connection compatibility. Concern is growing over these types of connections, and it’s become clear that training is not adequate to prevent these types of connections. According to the Joint Commission, “The basic lesson from these cases is that if it can happen, it will happen. Luer connectors are implicated in or contributed to many of these errors because they enable functionally dissimilar tubes or catheters to be connected.”
Action is being taken that would prevent these misconnections by ensuring that each type of tubing has its own, non-compatible connector. The Association for the Advancement of Medical Instrumentation (AAMI) is leading an international initiative to develop small-bore connectors standards. Public review of the standards is now available (along with other helpful information including case studies) on the AAMI website. The State of California has passed legislation requiring manufacturers of intravenous, epidural or enteral feeding devices to implement the new standards that aim to prevent misconnection, though it does not take effect until January 1, 2016.
Connectors meeting the new, non-compatible standards are becoming available but compatible connectors may still be in use and in inventory systems. To limit risk of patient death or serious impairment while the new connectors are phased in, TJC recommends that tubing is traced from the patient to its point of origin every time it is connected, disconnected, or during a patient hand-off. Labeling high-risk tubing and routing tubes and catheters in specific directions (towards the head for IVs; towards the feet for enteric feeding tubes) has also been recommended to reduce the risk of misconnection.
Going forward, only equipment that is incompatible with female luer connections on IVs should be purchased for all non-IV equipment and acceptance testing should be performed on new purchases to ensure it is not compatible with IV tubing connections.
The cause-and-effect relationships leading to the patient safety risks, and the solutions that are being recommended can be visually diagrammed in a Cause Map, or visual root cause analysis. To view a one-page overview of the issue, please click on “Download PDF” above.