Sentinel Event Alert - 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 misconnectionsThe 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:·
- Intravenous infusions connected to epidural lines, and epidural solutions (intended for epidural administration) connected to peripheral or central IV catheters. ·
- Bladder irrigation solutions using primary intravenous tubing connected as secondary infusions to peripheral or central IV catheters. ·
- Infusions intended for IV administration connected to an indwelling bladder (foley) catheter. ·
- Infusions intended for IV administration connected to nasogastric (NG) tubes. · Intravenous solutions administered with blood administration sets, and blood products transfused with primary intravenous tubing. ·
- Primary intravenous solutions administered through various other functionally dissimilar catheters, such as external dialysis catheters, a ventriculostomy drain, an amnio-infusion catheter, and the distal port of a pulmonary artery catheter.
What?! What kind of moronic neanderthal nurse connects an IV to an NG tube, Foley, or epidural?! The connection ports aren't even compatable! I guess this should teach a lesson about labeling your IV tubings but something tells me if the nurse found a way to do this she/he would probably miss the label. I really thought when my professor sent us this link that this was an April Fools joke.
Frustrating day in clinicals. Patient with severe edema to penis and scrotum, severe pain and tenderness, also incontinent of stool with severe diarrhea....you do the math.
Patient had a urethral stent placed and had a circumcision-like incision on his penis yesterday. Edges were approximated yesterday. Today his penis looked like a cauliflower. Incision had split open.
I told nurse (who didn't see him yesterday) who called doctor. Doctor said "It actually looks better today" The only time he saw him was at 4 am, he either didn't look or it happened afterward.
I also asked nurse for something better then vicodin for pain. She refused to ask the MD for that saying it would make him too altered. (Did I mention the pt had alzheimer's?)
Bottom line....No one is gonna listen to the student, my patient is suffering and being tortured, and I'm not allowed to call doctors or family to do anything about it. My instructor caved to the majority too. (His family is only available by phone....they live locally....he's had no visitors)