Making the Right Connection: Ending Tubing Mishaps in Healthcare

Laura A. Stokowski, RN, MS

Disclosures

October 06, 2014

In This Article

Misconnections in Healthcare

A pediatric intensive nurse was taking care of a very fussy baby girl on the night shift. The baby had a urea cycle defect (an inborn error of metabolism) and, shortly after birth, developed a high blood ammonia level along with other metabolic aberrations, for which she underwent peritoneal dialysis. She had a gastrostomy, a central line, and a peritoneal dialysis catheter in place, which had been left in situ until it was certain that she would not need further dialysis. She was receiving gastrostomy tube feedings every 3 hours. The nurse positioned the end of the feeding tube outside of the swaddled blankets for easy access, allowing her to connect the feeding pump and feed the baby without unwrapping and waking her if she slept through feeding time. It was later discovered that the nurse had inadvertently infused the baby's formula into the peritoneal dialysis catheter rather than the gastrostomy tube. The infant subsequently became very ill and suffered a setback.

Accidental tubing misconnections happen in healthcare, and the consequences can be deadly. No one knows precisely how frequently these errors occur, because they are largely unreported unless they result in patient harm, or they might be reported as a wrong-route medication error rather than a tubing misconnection incident. A recent literature review found 116 case reports of tubing misconnections, involving 21 deaths from sepsis or embolus. Other harmful consequences of these cases included hypersensitivity reactions, hypercoagulopathy, renal failure, multi-organ system failure, permanent neurologic damage, and respiratory arrest.[1]

The US Food and Drug Administration (FDA)[2] has received many reports on misconnections, both fatal and nonfatal, such as the following:

Liquid formula or medication is administered into the bloodstream when inadvertently connected to an intravenous (IV) port.

A noninvasive blood pressure line is connected to an IV line, injecting an air embolism into the circulation.

An epidural infusion is connected accidentally to an IV line, infusing the anesthetic directly into the bloodstream.

An intravenous line was connected to the nebulizer port of a respiratory circuit, flooding the patient's lungs with fluid.

A feeding tube was connected to the irrigation port of an inline suction system, delivering enteral feeding into the lungs.

Bladder irrigation fluid was connected to an IV line.

A Foley catheter was connected to the end of a patient's nasogastric tube, and urine began traveling up into the patient's feeding tube.

The types of tubing involved in misconnections are known as "small-bore catheters," which have a diameter less than 8.5 mm. Typically, small-bore catheters have Luer connectors: either Luer slip or Luer lock (which must be twisted to secure the connection). These Luer connectors, used on all types of small-bore catheters—IV tubing, enteral tubing, respiratory circuit ports, and urinary catheters—are compatible, making misconnections not only possible, but inevitable (Figure 1).

Figure 1. Simulation showing how a medication was inadvertently injected into a patient's tracheostomy cuff port. The patient had a central line with 3 injection ports in near proximity to the tracheostomy port. Courtesy of the US Food and Drug Administration

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