Caution: tubing misconnections can be deadly

AORN Journal, March, 2007 by Suzanne C. Beyea, Debora Simmons, Rodney W. Hicks

In April 2006, The Joint Commission issued a Sentinel Event Alert pertaining to the risk of tubing misconnections. (1) This alert describes injury to one patient who suffered permanent loss of function and the deaths of eight patients as the result of tubing misconnections. Every perioperative clinician should be aware of and learn how to avoid this common and potentially deadly error.

A tubing misconnection occurs when a nurse or other clinician unintentionally connects one end of a tube or catheter to the wrong tube or device. For example, one common misconnection occurs when a member of the health care team connects the male end of an enteric feeding tube to an IV catheter or a peritoneal dialysis catheter. It also is possible for a blood pressure insufflator tube to be connected to an IV catheter. (1)

Misconnections also can occur when a clinician uses a universal type of connector (eg, a 5-in-1 connector). The use of these connectors facilitates the joining of two types of tubing, even in situations when the tubes never should be joined. Additionally, many misconnections occur because various types of tubing, ports, and other medical devices use the same type and size connection, allowing for easy misconnection.

According to the Sentinel Event Alert, the US Pharmacopeia has collected more than 300 incident reports of misconnection problems. (1) These reports identify many misconnection errors such as the connection of IV fluids to

* indwelling urinary catheters,

* epidural catheters,

* nasogastric tubes,

* the distal port of a pulmonary artery catheter, and

* external dialysis catheters.

In one perioperative case, an IV piggyback antibiotic was connected to the ventriculostomy drain of a patient in the postanesthesia care unit. (1)

Other published sources reveal tragic events that have occurred as the result of tubing misconnections, (2) such as reports of nurses who have inadvertently administered breast milk or formula to neonates via the IV route. Other devastating errors include the connection of a sequential compression device to an IV administration set or the fatal error of infusing intrathecal vincristine. (2)

COMPLEX TUBING REQUIREMENTS

The Sentinel Event Alert on tubing misconnections warns that "if it can happen, it will happen." (1) Considering that most clinical situations have complex tubing requirements with various tubing types, it is remarkable that more errors do not occur. It is not unusual for one surgical patient to have a nasogastric tube, a central or peripheral IV line, an indwelling urinary catheter, sequential compression stockings, and tubing for an epidural or patient-controlled analgesia pump. In addition, patients also may have dialysis catheters, blood administration sets, or other drainage systems. As tubing is added, the potential for misconnection increases.

Another factor that can result in confusion or error is when any type of tubing is used for a nontraditional purpose. Consider the practice of using an indwelling urinary catheter for wound drainage or for draining an inflamed gall bladder. A nurse might question, "Is it a Foley or a choleFoley?" This multipurpose use of tubing can easily result in confusion when experienced clinicians are rushed or distracted when providing care.

TUBING CONNECTIONS

Tubes often are connected using a Luer-lock connection system (ie, the connection is made by rotating the connector by a half or three-quarter turn). Most clinicians are familiar with Luer-lock connections, which are used to secure W tubing to an IV needle. The locking mechanism provides security for the IV connection and helps prevent accidental disconnection. Luer-lock connections also can be found on a wide variety of tubing.

Another common type of tubing connection is the Luer-slip connection (ie, the connection is made by inserting the tapered male end into the female receptor). Although Luer-slip connections are easier to make, they are somewhat less secure. This type of connection often is used between an indwelling urinary catheter and a drainage system. To secure this type of connection, nurses often tape the two ends to prevent the tubing from accidentally disconnecting.

Unfortunately, no published manufacturing standards exist to guide manufacturers in their use of these varied connections. This has resulted in various manufacturers using connectors that are nearly uniform in size, subsequently allowing misconnection errors to occur. These errors are more likely to happen when a clinician attempts to connect two tubes that should not be connected but for which making a connection is possible. In fact, the misconnection actually may appear to be correct.

PREVENTION STRATEGIES

Suggested strategies to prevent this type of error seem obvious and frequently focus on developing manufacturing standards for the various tubing types so that misconnections simply cannot occur. Despite the Joint Commission's recommendation that hospitals avoid buying non-IV equipment that is capable of connecting with patient IV equipment, these products continue to be used, and errors continue to occur.