The risk of connecting tubing incorrectly has been at the forefront in patient safety for some time now. There are many reports in the literature and on-line of tubing misconnections with catastrophic consequences. I did a survey of practices regarding the use or non-use of enteral only tubing in the neonatal intensive care less than 1 year ago. Even at that time, there were about 26% of respondents who were not using a dedicated enteral only system or who were not using oral syringes for oral medications.
This was a fairly small survey (76 respondents) with responses from across the United States and a few from Australia and Canada. However, even with the small sample size, it is obvious that this is still a problem.
In a recent article, Simmons and others reviewed 116 reported cases of enteral to parenteral tubing misconnections.1 Of these, 30 involved children/infants and in 26 cases, the patient age was not specific. Based on these incidences and current expert recommendations to prevent tubing misconnections, it was determined that only a redesign of the tubing to physically prevent this connection would be effective. While the common response is to just “be more careful”, I’m certain that those who made this error all believed they were practicing with care at that point in time. However, there are many distractions and other reasons why, if it is possible, it will happen eventually. Of interest, in my survey, with almost two-thirds of respondents having more than 10 years of experience, when asked if they were concerned about making a tubing misconnection, 59% responded that they were “least concerned” with less than 8% responding that they were “very concerned”. However, when asked if they were concerned about new staff making a tubing misconnection error, 16% responded they were very concerned. However, the reality is that years of experience is often not a factor in these types of errors. Other factors like fatigue, busy-ness, distractions, and others are far more frequent. In fact, in my experience, the grave errors I have seen are not usually made by new staff. It is the more experienced staff who become used to a routine and may not be as thorough in checking every step or are called upon to do more than one task simultaneously that are more likely to make the errors.
So, what can you do to prevent tubing misconnection errors? As determined by Simmons and others, the only real prevention is to eliminate tubing that can be connected incorrectly. Enteral tubing should not connect to IV tubing and vice versa. There are guidelines being developed through the International Standards Organization (ISO) which are expected to be available in 2013 regarding manufacturing of tubing types to prevent misconnections. However, these will be voluntary guidelines. In the meantime and on the user end, the Institute of Safe Medication Practices (ISMP) and Baxter Healthcare’s Clinical Center of Excellence have joined together in creating a self-assessment tool for hospitals to evaluate the risk of tubing misconnections. This tool can be downloaded by healthcare professionals only at http://www.baxter.com/healthcare_professionals/clinical_center_of_excellence/toolkit_download.html?token=184.108.40.206. This tool provides the user with a manner in which to evaluate current delivery systems and mating devices. Ease of connection and potential for patient harm are evaluated and a risk priority score is assigned. This risk priority score can then be used to aid in making system changes that will prevent tubing misconnections.
We have learned so much about patient safety and safety in general both from experiences in our own field as well as safety work and experience in other fields. While some safety recommendations from other fields, such as the airline industry, may be difficult to apply when human factors and disease with all its idiosyncrasies are the subject of the work, this safety factor and change in practice and design certainly can be applied.
1. Simmons D, Symes L, Guenter P, Graves K. Tubing misconnections: Normlization of deviance. Nutrition in Clinical Practice. 2011;26(1):286-293.