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Tube misconnections in critical care

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Tubing misconnections in critical set up is often a grave error which needs to be addressed well with policies and standard operating procedures. A good understanding of the problem by the team will go a long way in preventing this mishap to ever happen in your team.

Published in: Healthcare
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Tube misconnections in critical care

  1. 1. Dr.Shailendra.V.L. Director of Patient Safety Al Bukeriya general hospital
  2. 2. LookLook –– CheckCheck –– ConnectConnect • Misconnecting medical device tubing can lead to serious patient harm or death. The FDA is working with standards organizations, the Joint Commission, and professional groups to support the correct use of device connectors to reduce the chance of tubing misconnections • Ensure all clinicians and providers are trained in advance of about connectors to avoid any problems with misconnections • Advise all staff to not modify or adapt the device or its connector outside of its intended use, in order to prevent misconnections.
  3. 3. Case studyCase study • An infant in the pediatric intensive care unit had both a feeding tube and a trach tube • The feeding tube was inadvertently placed in the trach tube and milk was delivered into the infant’s lungs • The infant died • THE JOINT COMMISSION2 SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion
  4. 4. Feeding Tube Erroneously Connected toFeeding Tube Erroneously Connected to Trach TubeTrach Tube
  5. 5. Case studyCase study • An anesthetist and a midwife mistakenly connected an epidural set to the patient’s IV tubing • The epidural medicine was delivered to the IV • The patient died • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: For certain high-risk catheters (e.g., epidural, intra-thecal, arterial), label the catheter and do not use catheters that have injection ports •
  6. 6. Epidural tubing erroneously connected toEpidural tubing erroneously connected to IV tubingIV tubing
  7. 7. Case studyCase study • A child in a pediatric intensive care unit had both an IV line and a trach tube • The IV tubing was mistakenly connected to the trach cuff port • The IV fluid over-expanded the trach cuff to the point of breaking and continuous IV fluids entered the child’s lungs • The child died • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Emphasize the risk of tubing misconnections in orientation and training •
  8. 8. IV tubing erroneously connected to trachIV tubing erroneously connected to trach cuffcuff
  9. 9. Case studyCase study • During a nebulizer treatment, the patient’s oxygen tubing fell off the nebulizer and the patient’s IV tubing was inadvertently attached to the nebulizer • When the patient inhaled, a moderate amount of IV fluids was aspirated into the patient’s lungs • The misconnection was identified by the respiratory therapist and the patient survived • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Do not purchase non-intravenous equipment that is equipped with connectors that can physically mate or attach with a female Luer IV line connector
  10. 10. IV tubing erroneously connected toIV tubing erroneously connected to nebulizernebulizer
  11. 11. Case studyCase study • A patient’s oxygen tubing became disconnected from his nebulizer and was accidentally reattached to his IV tubing Y-site by a staff member who was completing a double shift • The patient died from an air embolism, even though the connection was broken within seconds • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Identify and manage conditions and practices that may contribute to health care worker fatigue, and take appropriate action
  12. 12. Oxygen tubing erroneously connected to aOxygen tubing erroneously connected to a needleless IV portneedleless IV port
  13. 13. Case studyCase study • An ER patient had an IV heparin lock but no IV fluids had been started. The patient also had a noninvasive automatic BP cuff placed for continuous monitoring • The BP cuff tubing was disconnected when the patient went to the bathroom • When she returned, her spouse mistakenly connected the BP cuff tubing to the IV catheter and approximately 15 mL of air was delivered to the IV catheter • The patient died from a fatal air embolus, despite resuscitation efforts • POTENTIAL FOR HARM: High • Inform non-clinical 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 •
  14. 14. Blood pressure tubing erroneouslyBlood pressure tubing erroneously connected to IV catheterconnected to IV catheter
  15. 15. Case studyCase study • A nurse’s aide inadvertently connected a patient’s IV tubing to the nasal oxygen cannula upon transfer to the step down unit • The misconnection was not noted until four hours later, when the patient complained of chest tightness and difficulty breathing • The patient was treated for congestive heart failure and survived • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Recheck connections and trace all patient tubes and catheters to their sources upon the patient’s arrival in a new setting or service as part of the handoff process. Standardize this “line reconciliation” process. •
  16. 16. IV tubing erroneously connected to nasalIV tubing erroneously connected to nasal cannulacannula
  17. 17. Case studyCase study • The patient had both a central line with three ports and a trach tube • Medicine intended for the central line was inadvertently injected into the trach cuff • The trach cuff was damaged and the medicine entered the patient’s lungs • A new trach tube was inserted and the patient survived • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion •
  18. 18. Syringe erroneously connected to trachSyringe erroneously connected to trach cuffcuff
  19. 19. Case studyCase study • A patient’s feeding tube was inadvertently connected to the instillation port on the ventilator in-line suction catheter • Tube feeding was delivered into the patient’s lungs • The patient died • POTENTIAL FOR HARM: High • Emphasize the risk of tubing misconnections in orientation and training •
  20. 20. Enteral feeding tube erroneously connectedEnteral feeding tube erroneously connected to ventilator in-line suction catheterto ventilator in-line suction catheter
  21. 21. Case studyCase study • A patient admitted for stroke had a pulsatile anti-embolism stocking (PAS) on the left lower extremity and an IV heparin lock in the right ankle • The patient was alert and oriented on admission but shortly after was found unresponsive and cyanotic • The PAS pump tubing was found connected to the IV heparin lock in the patient’s right ankle • The patient died of a massive air embolus • POTENTIAL FOR HARM: High • THE JOINT COMMISSION SAFETY TIP: Manufacturers should implement “designed incompatibility” as appropriate, to prevent dangerous misconnections of tubes and catheters •
  22. 22. Pulsatile anti-embolism stockingPulsatile anti-embolism stocking erroneously connected to IV heparin lockerroneously connected to IV heparin lock
  23. 23. CASE STUDYCASE STUDY • A child had both a gastric feeding tube for nutrition and an IV for medicine and hydration • When the child’s gown was changed, a family member inadvertently attached the IV tubing to the gastric feeding tube • The medicine was delivered through the feeding tube into the stomach • There was no patient harm since the event was noted in a timely manner • POTENTIAL FOR HARM: Moderate • THE JOINT COMMISSION SAFETY TIP: Inform non-clinical 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 •
  24. 24. Foley catheter erroneously connected toFoley catheter erroneously connected to NG tubeNG tube
  25. 25. Ensure that health-care organizations have systems and procedures in place which: • Emphasize to non-clinical staff, patients, and families that devices should never be connected or disconnected by them. Help should always be requested from clinical staff. • Require the labeling of high-risk catheters (e.g. arterial, epidural, intrathecal). • Use of catheters with injection ports for these applications is to be avoided. • Require that caregivers trace all lines from their origin to the connection port to verify attachments before making any connections or reconnections, or administering medications, solutions, or other products.
  26. 26. Ensure that health-care organizations have systems and procedures in place which: • Include a standardized line reconciliation process as part of handover communications. • This should involve rechecking tubing connections and tracing all patient tubes and catheters to their sources upon the patient’s arrival in a new setting or service and at staff shift changes. • Bar the use of standard Luer-connection syringes to administer oral medications or enteric feedings. • Provide for acceptance testing and risk assessment (failure mode and effects analysis, etc.) to identify the potential for misconnections when purchasing new catheters and tubing.

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