This document provides guidance on line tracing and reconciliation to ensure patient safety. It outlines that errors can occur with incorrect solutions, pump programming, or line/catheter connections. The process involves physically tracing all lines from their source to the patient and reconciling solutions and settings against orders. All connections must be verified and labeled during handoffs or transitions. Examples of infusion errors are provided such as administering the wrong solution or dose.

1. ELINORE MATIGA
NCETD COORDINATOR
LINE TRACING
and LINE
RECONCILIATION

2. PURPOSE
1. To provide a safe environment for
our patients attached to various types
of medical tubing.

3. WHEN DOES ERRORS HAPPEN?
Errors occurred with hanging
the incorrect solution/medication

4. ERRORS OCCURRED DURING
PUMP PROGRAMMING

5. ERROR OCCURRED IN
CONNECTION OF THE LINE

6. TUBING OR CATHETER TYPES CAN BE,
BUT ARE NOT LIMITED TO, THE
FOLLOWING:
Peripheral Intravenous Tubing
Central Venous Catheters
Blood Administration Tubing
Tracheostomy Cuff Inflation Tubes
Bladder (Foley) Catheters
Nasogastric Tubes, Chest Tube
Oral Gastric Feeding Tubes

7. Line / Tube Reconciliation is a
process that requires:
A. Placing your hand on each
infusion and physically tracing
the line from the solution,
through the pump and into the
patient.

8. B. Reconciling the accuracy of the
solution and pump settings against
a primary source (e.g. MAR, order).
1. Verify fluids, meds & blood and
enteral products against order
2. Verify correct pump settings
3. Verify the connection is secured
to the correct route

10. LINE AND TUBING TRACING
Trace ALL tubes and lines from the patient
to the point of origin:
Before connecting or
reconnecting any device
or infusion
At any transition, such as
to a new setting or service
As part of the hand-off
process

11. Whenever possible, route tubes &
catheters having different
purposes in different standardized
directions.
a. IV lines routed toward the
head
b. Enteric lines toward the feet

12. Use oral medication syringes
to deliver medication.
“Do not use a standard luer
syringe for oral medications or
enteric feedings”.

14. HANDOFF / ENDORSEMENT, THE LINE
RECONCILIATION PROCESS INCLUDE:
Re-checking tubing and catheter
connections
Tracing all patient tubes and
catheters to their sources for correct
route
Labeling all tubes and catheters at
the point(s) of connection

15. Infusion Errors Examples include:
• A DKA patient was bolused with D5 0.45 % NaCl
instead of D5W.
• A 20mEq KCl IVPB was infused wide-open
because it was connected to a port below the
pump rather than above it
• A wrong dose of Dopamine was
administered because an incorrect weight was
entered on the patient
• Regular Insulin was changed from single-strength to
double-strength, but the Alaris pump was not
reprogrammed accordingly, delivering twice the
intended dose