Alert issued on tubing, catheter misconnections
Alert issued on tubing, catheter misconnections
Luer connectors a common component
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has issued a Sentinel Event Alert that asks health care organizations to pay special attention to how tubing and catheters are connected so dangerous misconnection errors can be prevented.
The Joint Commission says nine cases involving tubing misconnections had been reported to its Sentinel Event Database by early April. These cases, which affected seven adults and two infants, resulted in eight deaths and one instance of permanent loss of function. Reports in the media and to organizations such as ECRI (formerly the Emergency Care Research Institute), the FDA, the Institute for Safe Medication Practices, and United States Pharmacopeia (USP) indicate that misconnection errors occur with "significant frequency and, in a number of instances, lead to deadly consequences," the Alert says.
Several different types of tubes and catheters are involved in the misconnections reported to the Joint Commission. They include: central intravenous (IV) 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 (four cases); injection of barium sulfate (gastrointestinal contrast medium) into a central venous catheter (one case); an enteric tube feeding into a peritoneal dialysis catheter (one case); a blood pressure insufflator tube connected to an intravenous catheter (two cases); and injection of intravenous fluid into a tracheostomy cuff inflation tube (one case).
Many of these misconnection cases and of the more than 300 reported to USP’s databases, however, involve luer connectors, the small devices used in the connection of many medical components and accessories. Luer connectors are common to many of these errors because they enable functionally dissimilar tubes or catheters to be connected, the Joint Commission says. Examples of misconnections involving luer connectors include the following:
- Capnography sampling tube to an intravenous cannula.
- Enteral feeding set to a central venous catheter.
- Enteral feeding set to a hemodialysis line.
- Noninvasive blood pressure insufflation tube to a needleless IV port.
- Oxygen tubing to a needleless IV port.
- Sequential compression device hose to needleless "piggyback" port of an IV administration set.
Even with these problems, no standards are currently published that specifically restrict the use of luer connectors to certain medical devices. The solution to reducing these errors, health safety experts say, is to use engineering controls that respect how products and devices are designed and to re-engineer work practices. For example, Stephanie Joseph, project engineer for ECRI, recommends that hospitals avoid buying nonintravenous equipment that can mate with the luer connectors on patient IV lines. Clinicians should also trace all lines back to their origin before connecting or disconnecting any devices or infusions.
The Joint Commission has offered recommendations and strategies of its own to help health care organizations reduce tubing misconnection errors. These are:
- Do not purchase nonintravenous equipment that is equipped with connectors that can physically mate with a female luer IV line connector.
- Conduct acceptance testing (for performance, safety, and usability) and, as appropriate, risk assessment (e.g., failure mode and effect analysis) on new tubing and catheter purchases to identify the potential for misconnections and take appropriate preventive measures.
- Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.
- Recheck connections and trace all patient tubes and catheters to their sources upon the patient’s arrival to a new setting or service as part of the hand-off process. Standardize this "line reconciliation" process.
- Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially important in the care of neonates.
- Inform nonclinical 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.
- For certain high-risk catheters (e.g., epidural, intrathecal, arterial), label the catheter and do not use catheters that have injection ports.
- Never use a standard luer syringe for oral medications or enteric feedings.
- Emphasize the risk of tubing misconnections in orientation and training curricula.
- Identify and manage conditions and practices that may contribute to health care worker fatigue, and take appropriate action.
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