Figuring out why accidents might happen can be much more difficult than understanding why an accident actually occurred. Certain things (such as the lack of a stop sign at a blind intersection) seem inherently obvious that an accident will most likely happen.
However, things like connecting a blood pressure monitor tube to an IV seem nearly impossible to have happened by accident… and yet they have been reported. 1
Nevertheless, it is important to learn from the mistakes of others, and to avoid the mentality of “that would never happen here, or to me.”
What is the risk of a misconnection?
There have been a number of reports over the years of enteral tubing to IV tubing misconnections, most often in the neonatal population. 2 Possible risks that may have contributed are:
Risk 1: Similar equipment / fluid
Part of the reason these misconnection reports happen more frequently in the NICU population is likely related to the fact that most, if not all, of our patients at one time or another have an IV infusing fluid and a gastric tube in place. Many infants have both in place for a prolonged period of time, often more than a week.
In many cases, both are infusing liquid, sometimes intralipids and a milk feeding, both of which look very similar. Tubing for intralipids and milk feedings may also be the same tubing.
Risk 2: Dim lighting
The attempt to keep infants protected from bright lights means NICU lighting is low (at least into the incubator where the tubing is ultimately connected).
Risk 3: Lack of dedicated attention
Since enteral feeding is such a commonplace occurrence in the NICU, nurses connect and disconnect tubing many times in a 12-hour shift, often at least four times. Multiply that by a three-infant assignment, and the nurse may be connecting tubing twelve times during her shift. This is a very routine procedure, and therefore may not get the attention it merits.
Risk 4: Established procedure/practice that is not a forced function
Tubing is very close to other tubing in the bed itself. Infants are in incubators that measure two feet by three feet, with tubing and wires strung around them, the blankets, and positioning devices. The IV tubing and enteral feeding tubing may even be lying next to each other.
Some units and nurses have a practice of placing IV tubing toward the head of the bed and feeding tubing toward the foot of the bed. But if the nurse on the previous shift wasn’t aware of this practice, (such as a nurse new to the unit, or nurse floating into the unit and caring for the infant, or other personnel changes), it could become displaced from its usual position. The nurse who is used to this practice would then change tubing and possibly misconnect, as it is her routine to connect IV tubing at the top of the bed and feeding tubing at the bottom of the bed.
Risk 5: Interruptions
I was recently fortunate to hear a research presentation about interruptions in care. This was specific to feedings in the NICU, and how often nurses get interrupted during a bottle feeding. Each NICU is likely to be somewhat different, but I’m sure the neonatal nurses reading this will recognize that this is indeed very common.
We’ve worked hard to increase safety related to medication administration and eliminate interruptions, as it is well recognized that this increases the risk of error. And yet, how common is it that nurses are interrupted when placing feeding syringes on the pump and connecting the tubing to the infant’s gavage tube? It’s probably just as common as getting interrupted during bottle feeding.
Interruptions take your attention away from the task at hand. Even if you quickly come back to the task, your mind may not be back quite so readily. Instead, perhaps you are still listening to the alarm next to the bedspace where you are working to see if the infant will recover quickly enough, or wonder if someone else will respond to that alarm, or you’re thinking about the order you were just given by a care provider, or you’re focused on a question a parent has asked… the list goes on.
How can we prevent misconnections?
The safety literature recommends the use of “forced functions.” That means that something can only be done in the correct way. 3
Simply raising awareness about the risk of tubing misconnections, changing colors, and having dedicated pumps for feeding may decrease the risk of these misconnections but doesn’t prevent it entirely.
The advent of “enteral only” connections was a first step on this path, with manufacturers creating sometimes proprietary connections. This created problems with not all connections being dedicated, such as syringes that could be connected to IV tubing when meant for oral administration, parts of the tubing pathway being interchangeable, and back orders that led to falling back on non-enteral tubing and/or syringes.
The next step was a move to the ENFit connector, which was a universal connector for enteral feeding and adopted by a majority of enteral manufacturers. This has led to some issues as well when implementing into practice, particularly with oral medication administration. However, as with any change in practice, there is a learning curve, and inevitable problems that need to be addressed along the way.
When making changes in practice, we must always evaluate the risks and benefits of the change itself and the resulting end practice. This is something that each neonatal unit must do, as practices and staff are individual. After all, in the end, something shown to be strikingly ineffective in preventing error is to simply say “be more careful.”
- Simmons D, Symes L, Guenter P, Graves K. Tubing misconnections: Normalization of deviance. Nutrition in Clinical Practice. 2011;26(1):286-293.