Preventing Medical Tubing Misconnections
By Alexis Reeves, RN, Director of Patient Safety Operations & Implementation
In one case, a patient requiring a lumbar drain for her scheduled procedure had her IV disconnected while her medical team rotated the operating table 180 degrees. When the anesthesiologist went to reconnect her tubing, she accidentally reconnected the IV line onto the receptor for the lumbar drain because his visibility was impaired by the patient’s drape. The error went unidentified long enough for 30 milliliters of propofol to be infused. When a nurse noticed the tubing error, the anesthesiologist immediately corrected the connection, and aspirated the unintended medication along with spinal fluid. The surgeon cancelled the case and the patient was transported to the ICU for further evaluation. Fortunately, the patient recovered and her procedure was completed at a later date. But this misconnection error exemplifies how problems can occur if a tube intended for one purpose easily fits into the space meant for another type of tube.
Hundreds of cases such as this one have occurred around the country, some of which have resulted in permanent loss of function or painful death. Rather than relying on individual organizations to conduct the engineering fix required to prevent patient harm, the International Standards Organization (ISO) has established new design standards to prevent these types of tubing misconnections from occurring. The ISO standard known as ISO 80369-1 addresses small bore connector standards. The new requirement will make it impossible for tubing designed for one purpose to be accidentally connected to a tube intended for another purpose.
Here at Stanford Health Care, we are in the process of replacing enteral feeding systems in the next few months, followed by epidural systems this summer. In the meantime, we have instituted safety measures such as “walking the line” and labeling the tube and lines in an attempt to prevent potential misconnections and patient harm.
When making tube connections, it is vitally important to follow these safety precautions:
· Have a clear visual confirmation.
· If in doubt, ask for a second set of eyes to assist.
· If you identify a potential failure or vulnerability either in the process or equipment, immediately contact the Patient Safety Department.
Remember, it is our jobs as health care professionals to keep patients safe. If you see something not quite right, speak up. You will be heard.