Tubing Misconnections - A Systems Failure With Human Factors: Lessons for Nursing Practice

Debora Simmons, MSN, RN, CCRN, CCNS; Krisanne Graves, BSN, RN, CPHQ

Disclosures

Urol Nurs. 2008;28(6):460-464. 

In This Article

Abstract and Introduction

Abstract

In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.

Introduction

Since 1972, there have been reports of failures to connect the correct tubing to intravenous, epidural, intracranial, intrathecal, and other high-risk systems (Berwick, 2001; Reason, 2004; Wallace, Payne, & Mack, 1972). In 2006, The Joint Commission published Sentinel Event Alert Number 36: Tubing Misconnections – A Persistent and Potentially Deadly Occurrence. The alert cited misconnections of central intravenous catheters, peripheral intravenous catheters, nasogastric feeding tubes, percutaneous enteric feeding tubes, peritoneal dialysis catheters, tracheostomy inflation cuff tubes, and automatic blood pressure insufflation tubes reported to The Joint Commission as sentinel events. However, the number reported to The Joint Commission may be a very low representation of the actual number of misconnections that occur (Aspden, Corrigan, Wolcott, & Erikson, 2004; The Joint Commission, 2006). Further review of misconnections reported to the United States Pharmacopeia found 300 cases that include connections of epidural lines to intravenous catheters, bladder irrigation solutions connected to primary infusion sets, intravenous infusions misconnected to in dwelling (Foley) catheters, and various other misconnections between critically incompatible infusion and drainage sets (Hicks & Becker, 2006). The common element in each misconnection is the luer tip, or small bore connector, the ubiquitous connector used in health care (see Figure 1). For this article, the term luer connector will be used.

Figure 1.

Example of a Luer Connector (Small Bone Connector)

The 2004 Institute of Medicine (IOM) report, Keeping Patients Safe: Transforming the Work Environment of Nurses, suggested that a basic knowledge of human factors and ergonomics is necessary to establish safer work processes in the nursing environment (Gosbee, 2002; Page, 2004). Tubing misconnections create one such hazard to patients that can be mitigated by a human factors approach. Learning from the incidence and prevalence of tubing misconnections provides an opportunity to translate recommendations from the IOM to the practice of nursing and to redesign the work environment of nurses to support safe patient care.

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