Various tubing misconnections have occurred for decades, often resulting in patient deaths. Reported cases have involved almost any catheter you can think of (substances intended for feeding tubes being given intravenously or via dialysis catheter, intravenous medications being given intrathecally, hypertonic intravenous contrast agents being given intrathecally for myelography, bladder irrigation solutions being given intravenously, intramuscular medications like Bicillin being given intravascularly, IV fluid being injected into a tracheostomy cuff, blood pressure cuffs being hooked up to IV lines, and many more examples).
A variety of contributing factors and root causes for such incidents have been identified. Obviously, the sheer number of tubes and catheters in patients is a big problem. Such are often arranged close together and often look very similar, prompting some to refer to “the spaghetti syndrome”. Failure to trace the tubing back from the patient to the origin is another issue. Particurly vulnerable times are at handoffs or when a patient goes from one unit to another (not just unit-to-unit transfers but especially trips to places like the radiology suite). And the usual environmental and personnel-related factors (poor lighting, staff fatigue, supply shortages, etc.) that are involved in many incidents also contribute here.
But the most salient feature, of course, is that the design of the systems allows 2 things to be connected that were never intended to be connected. The most successful safety interventions in any industry are constraints and forcing functions, i.e. designs that force someone to do something or not to do something. This particular issue is one that should be amenable to use of such forcing function solutions.
Given both the magnitude of the problem and the devastating consequences, several groups began collaborating several years ago to come up with new design solutions to prevent such inadvertent misconnections. The groups included ISO (the International Organization for Standardization), AAMI (the Association for the Advancement of Medical Instrumentations), the FDA, manufacturers and clinicians. Important contributions in the past have also come from ISMP, National Patient Safety Agency (UK), and the Pennsylvania Patient Safety Authority among many others.
The result of the collaboration is that several new sets of connector standards are forthcoming. The first ISO connector standard should be ready in the fall of 2014, with more to follow in 2014 and 2015. Timely is a new Joint Commission Sentinel Event Alert on managing risk during transition to the new ISO tubing connector standards (TJC 2014). While it contains many of the recommendations from its earlier sentinel event alert on tubing misconnections (TJC 2006) it focuses on the risks that might occur during the transition to the new tubing connector standards. It cautions that, though the new standards will ultimately improve patient safety, there could be new risks during this transition period.
The new Joint Commission sentinel event alert has many excellent recommended actions your organization should take. We won’t repeat them here. Go to the actual sentinel event alert and read them. Also see our previous columns on catheter and tubing misconnections listed below. There are links to some excellent resources in them, particularly our April 2012 What’s New in the Patient Safety World column“Tubing Misconnections” and August 23, 2011 Patient Safety Tip of the Week “Catheter Misconnections Back in the News”.
In addition to their recommendations, you should make monitoring of these systems a priority. It would be a good process to add to your “patient safety walk rounds” and doing periodic audits of your organizations practices is another. As before, this topic is an excellent process to conduct FMEA (failure mode and effects analysis) around.
Catheter/tubing misconnections are among the most devastating patient events we have seen, since many result in patient death. See our previous columns on this topic:
July 10, 2007 “Catheter Connection Errors/Wrong Route Errors”
November 2007 “More Patient Deaths from Luer Misconnections”
August 2009 “Catheter Misconnections Continue to Occur”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
April 2010 “RCA: Epidural Solution Infused Intravenously”
August 2010 “ISMP Advice on Catheter Misconnections”
August 23, 2011 “Catheter Misconnections Back in the News”
April 2012 “Tubing Misconnections”
TJC (The Joint Commission). Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards. Sentinel Event Alert 2014: 53: 1-6, August 20, 2014
The Joint Commission. Tubing misconnections—a persistent and potentially deadly occurrence. Sentinel Event Alert 2006; Issue 36 April 3, 2006
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