This has been a topic of discussion in healthcare for some time with many measures having been taken to avoid tubing misconnections. These included raising awareness of the problem, asking healthcare workers to be “more careful” and for healthcare staff to warn patients and visitors not to reconnect tubing that may have become disconnected. Several patient safety organizations have come up with steps to be taken to avoid this life-threatening complication.
It is important to note that many experts say the area of highest risk for tubing misconnections is the Neonatal Intensive Care Unit (NICU) The reasons for this have been discussed in a previous blog. The Joint Commission (JC) had a few items in a Sentinel Event Alert that should be warning signs of a possible misconnection.1 These are having to force-fit tubes together, having to use an adapter or using a tube or catheter for other than its intended or customary function. Historically, we have done all of these in the NICU!
Of course, the most important step in preventing misconnections is to design a system that will not allow the user to make an incorrect connection. This system has been designed and may soon be coming to your NICU. While tubing misconnections have occurred between various types of tubing, the most common is between tubing delivering an enteral feeding connected to intravenous tubing. Therefore, the new requirements will address this connection first. GEDSA (Global Enteral Device Safety Association), a non-profit group organized to address this concern, has a website that can be accessed for updates periodically as well as a checklist hospitals can use as a self-assessment (www.stayconnected2014.org). A design has been approved for new enteral connections and is anticipated for the U.S market beginning in Spring. This connection for enteral tubing and syringes will be called the ENFit. Click here to see illustrations of ENFit connectors on the GEDSA website
While this will provide additional safety, we know that anytime changes are made, mistakes are more likely. Getting used to the new equipment, changing over from current supplies to new supplies and transitioning presents problems. During the transition time when current tubing and syringe stock is still available but new supplies are coming in, adapters will be available. These adapters are intended to connect current enteral-only devices with the new ENFit connector, not intravenous devices and tubing to the new connectors. However, ISMP points out that one of the most common misconnection errors in the adult population is to connect an automatic blood pressure tubing to an intravenous line, particularly a central line. Once the blood pressure machine is programmed to automatically cycle and measure the patient’s blood pressure, it will instead pump air into the intravenous line. As most clinicians are aware, these two devices do not fit together particularly well. Therefore, some effort was involved in making that connection. Others shown on the FDA website are equally difficult to imagine. Some are done by non-clinical folks such as patients themselves or their families. However, some are done by nurses who are distracted and busy. It has been pointed out that while this new connector, the ENFit, is intended to provide that final level of safety making it “impossible” to make an improper connection, it can still happen. One quality expert says, “They will really have to work at making the wrong connection, but it will be done.”2 Connections between blood pressure tubing, oxygen tubing and IV tubing illustrate this.
It has been well documented that errors happen even to some staff who are thought of as the “best” nurses. While we are more alert to the newest staff making these errors, they and those around them often watch more closely. With more experience, simple things like connecting a feeding tube become “automatic” which leads to problems when new products and processes appear. In-servicing on the new products prior to rollout cannot be over-stressed. Many of us have experienced having a new product show up on the shelf or a new device on a patient without any training. In my own experience, it’s often on a Friday night at 5pm or after when support personnel are not readily available!! While these products may be pretty self-explanatory in some cases, it should always create questions in the careful clinician’s mind as to why the new product has suddenly appeared, what it replaces and why. So much more so a new connector and the adapters that will be used initially. The experts point out that if the connection is difficult to make, red flags should go up in one’s mind. Greater risk exists during the change over from the old enteral products to new enteral products. The most recent statement from the JC addresses recommended precautionary measures to be taken during the transition period as this is also recognized as a high-risk period.3
In summary, while these changes will ultimately lead to a safer environment, the transition time will still contain additional risk. However, the change must be made, both to improve patient safety and to meet regulatory requirements. I believe it is important to point out that in spite of enteral-only tubing having been available for some time now, not all hospitals are in compliance and enteral to IV misconnections are still happening. Don’t let it be you!
1. Joint Commission. Sentinel Event Alert Issue 36. April 3, 2006. Tubing misconnections – a persistent and potentially deadly occurrence.
2. New sentinel event alert targets tubing misconnections. Hosp Peer Rev. 2014 Oct;39(10):109-12.
3. Joint Commission, Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards. August 20, 2014.
Looking for additional reading from Sandy Beauman’s professional perspective?
View her recent blog entry, Infections and Feeding Tubes.
Click here to read the full blog entry.