Tubing Misconnections

Tubing Misconnections

In a tertiary healthcare setting medical devices are connected to patients for the purposes of delivering medications, gases & enternal feedings. These devices frequently have similar & often identical connectors. The multitude of similar connectors in a clinical environment may lead a patient care provider to connect two devices which have different intended purpose, thus leading to a "misconnection."





Please select from our list of sub-topics:

About Tubing Misconnections/Importance

Tubing Line and Reconciliation Process

Education and Awareness Materials

Example Policy and Procedure

Product- The Beata Clasp®: Encourages Tubing Awareness

Other Concerns/Options

Tubing Misconnections Resource Links




About Tubing Misconnections/Importance

In a tertiary healthcare setting medical devices are connected to patients for the purposes of delivering medications, gases & enternal feedings. These devices frequently have similar & often identical connectors. The multitude of similar connectors in a clinical environment may lead a patient care provider to connect two devices which have different intended purpose, thus leading to a "misconnection."

In April of 2006 Joint Commission on Accreditation of Healthcare Organizations issued a Sentinel Event Alert: Tubing Misconnections A persistent and potentially deadly occurrence

Goal 19

Prevent catheter and tubing misconnections

Requirement 19A

The organization takes steps to prevent catheter and tubing misconnections through risk assessment, line reconciliation procedures, and education.

Rationale for Requirement 19A

Tubing and catheter misconnections are frequent and preventable errors that have resulted in serious injury and death. The designs of many tubing and catheter devices and products can allow inadvertent misconnection, and therefore compounds the risk.

Implementation Expectations Requirement 19A

Identify potential misconnections through risk assessment of all existing catheters and tubes and when considering the purchase of new catheters and tubing, especially those with Luer connections.

As part of the handoff communication, develop a standardized "line reconciliation" process. Components of 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

Trace all lines from their sources to the patient before making any connections or reconnections, administering medications, solutions, or other products.

Educate all clinical and non-clinical staff about the hazards of misconnecting tubing and devices.

Background and Research:

Medical lines and tubing are abundant in clinical practice. It is not uncommon to see IV lines and other cables tangled when patients are mobile or in transport. Tubing is a potential source of harm when it becomes dislodged, impinged, entangled or wrapped around the patient's neck or limbs. Furthermore; the time required for nursing staff to untangle, reorganize or reinsert lines represents a significant operational inefficiency.3

Clinicians have repeatedly expressed frustration with the "spaghetti syndrome" of lines and tubing and negative effects on patient safety, although only a small base of research exists on the problem.4,5 Of 114 line, tube and drain incidents reported in one prospective ICU study, >60% were considered preventable. Of patients experiencing an incident, 56% sustained physical injury, 23% had an increased hospital stay and one patient died.1 An earlier prospective audit of intra-hospital transports found that 45% of complications experienced by critically ill patients were related to the transport environment, a category that included tubing entanglement and impingement. The study concluded the "mass tangle of lines" not only decreased hospital efficiency but increased the potential for medication error.2 Another study described two cases of strangulation by intravenous tubing in infants, one of which was fatal.6 The Emergency Care Research Institute (ECRI) database lists two additional cases of fatal strangulation by IV tubing occurring between 1984 and 1997.7 The actual risk of strangulation by IV tubing or other lines, however, is not known as there are no reporting mandates. Data may only be available in facility incident reports or through voluntary reporting, and are likely to be underreported. It is possible that the overall number of tubes and lines used per patient may increase the risk of adverse events; however, data are not available to support this supposition.

Prompted by the report on infant strangulation,6 the Canadian government sponsored a national patient safety workshop to mitigate the risk of strangulation and other problems caused by medical tubing and monitor leads. The workshop resulted in a set of guidelines for improving tubing and line safety.8 Recommendations included the adoption of technology to ensure properly separated, labeled and secured line connections as well as implementation of appropriate human factor engineering concepts to reduce the risk of tubing-related adverse events.

In 2006, the Joint Commission issued a Sentinel Event Alert regarding tubing and catheter misconnection errors, citing them as an important and under-reported error in health care organizations. At the time, nine cases involving tubing misconnections had been reported to the Joint Commission. These cases resulted in eight deaths and one instance of permanent loss of function. Often misconnection cases involve luer connectors - implicated because they enable functionally dissimilar tubes or catheters to be connected. But other identified causes included the routine use of tubes or catheters for unintended purposes (such as using IV extension tubing to extend enteric feeding tubes), and the positioning of functionally dissimilar tubes in close proximity to one another. The Joint Commission also cited movement of the patient from one setting or service to another, and staff fatigue associated with working consecutive shifts as contributing factors. ECRI recommended that the single most important work practice solution for clinicians is to trace all lines back to their origin before connecting or disconnecting any devices or infusions. The "spaghetti syndrome" of entangled and wrapped lines, however, presents an obstruction to clean tracing.

References

Needham DM, Sinopoli DJ, Thompson DA et al. (2005). A system factors analysis of "line, tube and drain" incidents in the intensive care unit. Crit Care Med; 33(8): 1701-1707.

Lovell MA, Mudaliar MY, Klineberg PL. (2001). Intra-hospital transport of critically ill patients: complications and difficulties. Anaesth Intensive Care; 4: 400-405.

Pittsburgh Regional Healthcare Initiative (PRHI). (2002). Untangling a problem at West Penn. PRHI Executive Summary: www.prhi.org. Pittsburgh Regional Healthcare, Pittsburgh PA.

Clark D. (1994). Untangling the "spaghetti syndrome" - inspiration for a business. Revolution; 4(4): 55-56.

Cook TM, Seavell CR. (1996). Patient transfer; what to do about the "spaghetti". Anaesthesia; 51(1): 90-91.

Garros D, King JW, Brady-Fryer B, et al. (2003). Strangulation with intravenous tubing: a previously undescribed adverse advent in children. Pediatrics; 111; 732-734.

Emergency Care Research Institute (ECRI). (2005). Adverse event database.

Health Canada & Canadian Association of Paediatric Health Centres (CAPHC). (2003). Patient safety workshop June 14th 2003: proceedings paper. Canadian Association of Paediatric Health Centres. Calgary, Alberta.

Joint Commission. (2006). Tubing misconnections - a persistent and potentially deadly occurrence. Sentinel Event Alert; Issue 36; April 3, 2006.

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Tubing Line and Reconciliation Process

1. Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.

2. Line reconciliation: Recheck connection & trace all patient tubes & catheters to their sources upon the patient's arrival to a new setting or service as part of the hand-off process.

3. 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

4. Inform non-clinical staff, patient 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.

5. Label epidural, intratheral and arterial catheters.

6. Use oral medication syringes to deliver medication; do not use a standard luer syringe for oral medications or enteric feedings.

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Education and Awareness Materials

The following posters may be used to prevent tubing misconnections by brining awareness to the potential danger to clinical staff, patients, and families. Posting in the patient's room instructs the patient and family to contact staff member for assistance with connecting or disconnecting any tubing, wires, equipment or devices. Posting in areas where staff gather allows all clinical staff to learn about the can learn the Tubing Line and Reconciliation Process.

Clinical Staff:

- Poster for Staff Areas

- Pocket Tubing Misconnection Cards

Non-Clinical (family/patient):

- Poster for Patient Rooms

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Example Policy and Procedure

Hospital Tubing Misconnection Policy/Procedure:

Purpose of policy: To provide a safe environment for our patients attached to various types of medical tubing.

Tubing or catheter types can be, but are not limited to, the following:

· Peripheral Intravenous Tubing

· Central Venous Catheters

· Umbilical Arterial Catheter Tubing (UAC)

· Umbilical Venous Catheter (UVC)

· Percutaneous Intravenous catheter (PIC)

· Peritoneal Dialysis Catheters

· Tracheostomy Cuff Inflation Tubes

· Automatic Blood Pressure Cuff Inflations Tubes

· Bladder (Foley) Catheters

· Nasogastric Tubes

· Oral Gastric Feeding Tubes

· Percutaneous Feeding Tubes

· In-Line Suction (Ballard)

· Blood Administration Tubing

· Ventriculostomy Tubing

· Epidural Catheters

· Arterial Lines

· Intra Aortic Balloon Pump (IABP)

· Chest Tube

Procedure:

Before attaching tubing to a patient, label the tubing near the connection point with the name of any fluid infusing and note the route of fluid by indication: IV, epidural, pressure line, feeding tube or specified other on the label.

Before connecting any new device or infusion to a medical tubing, always trace the tube or catheter from the patient to the point of origin.

Recheck connections and trace all patient tubes and catheters to their source upon a patient's arrival to a new unit or department.

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.

Turn on the light in a darkened room before connecting or reconnecting tubes or devices.

If a line disconnects in an area without a nurse, the clinical team member on the department where the patient is currently locate, may clean the tip of the catheter with alcohol and cap the tubing end with a needle cap and notify the nursing unit of the disconnect. Nursing will determine need fro immediate reconnect and provide nursing support for the reconnect if deemed necessary.

For an intubated infant with an oral gastric tube, place a purple color sticker to the NG/OG tube. Use only while the infant is on the ventilator.

Never use a standard luer syringe for oral medications or enteric feedings.

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Product- The Beata Clasp®: Encourages Tubing Awareness

The Beata Clasp® is a soft foam clasp that attaches to the hospital bedrail. Medical tubing, lines and drains fit securely into the product's bank of circular grooves. The clasp prevents tubing misconnections, line impingement, dislodging and entanglement by holding tubes in place within the grooves. The simple technology reduces the risk of adverse line, tube and drain incidents by keeping lines organized and neatly separated. Because tubing is prevented from falling to the floor, contamination risks to patient and safety hazard risks to caregivers and visitors are reduced.

Helping to focus on the 2006 Joint Commission on Accreditation of Healthcare Organizations' Sentinel Event Alert:

Tubing Misconnections A persistent and potentially deadly occurrence.

The Beata Clasp® provides a visual prompt that encourages the use of the Line Reconciliation Process during hand off communication.

www.BeataClasp.com

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Other Concerns/Options

Eliminating the interconnectivity between various medical tubing would be the ideal preventive measure to tubing misconnections. However, there is a extensive variety of tubing and connector manufactures and creates an obstacle towards such a mandate.

There are several steps your clinical facility can take to prevent tubing misconnections.

Education:

-All clinical and non-clinical staff need to be made aware of potential serious consequences that could result from s tubing misconnection.

-Use posters, handouts, story boards, or staff meetings to inform staff of ways to prevent tubing misconnections and any protocols that have been set in place.

-A variety of people (e.g., ancillary personnel, medical and nursing students) are present in patient care units but do not know the correct safety measures to follow. Encourage everyone who is uncertain to inform the correct trained licensed professional who can accurately trace the line from the patient to the point of origin.

Purchasing Department:

-When purchasing products related to tubing and connectors, select items with parts that can not be forced together.

-Look for items that help keep tubing or secure. (example: www.BeataClasp.com)

-Provide units with sticker labels to place on tubing at beginning and end points.

Staff:

-Take the time to become familiar with the medical equipment used each facility you work at and be able to identify the potential for misconnections.

-Never assume two pieces of tubing connect because of matching adaptors, or "standard/familiar" tubing types. Always trace lines and read labels of tubing, solutions, mediations, etc. Verification!

-Turn down requests to connect or disconnect medical tubing when it is not in your scope of practice..

-Patients and family members try to assist in their own or loved ones care so be sure to communicate about tubing safety with them (see Patient & Family section below).

Patient & Family:

-It is the staffs responsibility to encourage questions from the patient and family members regarding proper tubing management.

-Make sure signs in patient rooms are clearly visible and explain the need to contact staff members for assistance with connecting or disconnecting any tubing, wires, equipment or devices.

-Explain to the family and patient what each piece of tubing, wire, or lines' function is so they can also monitor for unintended variation

Administration:

-Identify all types of staff at your facility who may come into a situation where connecting, disconnecting, or reconnecting various forms of tubing attached to patients is needed.

-Define in job descriptions of all members of your facility (e.g., technicians who work in diagnostic units, transport staff, nursing assistants, students, physicians) whether the task of performing connections/disconnections of tubing falls within a safe and acceptable scope of practice.

-Prohibit the requesting of untrained staff to inappropriately perform these task by other staff.

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Tubing Misconnections Resource Links

Multiple, overlapping resources and initiatives exist related to patient safety at the federal and national levels. Some of the initiatives create regulations or standards that health care organizations must adhere to; others are recommendations only and may be translated into regulations. The collective goal of these many activities is to improve patient safety.

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