Are tubing errors harming patients at your facility?

Recent sentinel event alert warns of errors

Tubing from a portable blood pressure monitoring device is inadvertently connected to a patient's intravenous (IV) line, and a fatal air embolism results.

Oxygen tubing is mistakenly connected to the IV line of a pediatric patient receiving medication via a nebulizer to treat asthma. The oxygen tubing is disconnected in seconds, but air was allowed into the IV tubing and the child dies instantly.

These are two examples of patient deaths resulting from tubing misconnection errors reported to the Institute for Safe Medication Practices (ISMP). A recent sentinel event alert from the Joint Commission warns that these dangerous errors are continuing.

Organizations are challenged to develop successful interventions to ensure that nurses always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.

Part of administering an IV medication is making sure the tube is going where you want it to go, says Alison Page, MHA, director of patient safety at Fairview Hospital in Minnesota. "We consider 'tracing your tube' to be a part of standard nursing care," she says. "Some of these errors are also caused by people forcing tubes to connect where they should not." For example, a nurse may be used to giving a certain drug intravenously, so she forces the tube into the IV adapter even though it is supposed to connect to the feeding tube.

At Paradise Valley Hospital in National City, CA, a multidisciplinary team was formed with representation from inpatient, outpatient, and home care services, to review all aspects of tubing selection, use, and education. "This is a serious problem," says Catherine Fay, RN, director of performance improvement. "We anticipate that the committee will identify best practices and measures for monitoring."

At Covenant HealthCare in Saginaw, MI, the first step that quality professionals are taking is to give the Sentinel Event Alert recommendations to the value analysis committee. "Any equipment that is purchased goes through this committee for review," says Ann D. Law, RN, outcomes specialist. "Secondly, we will take the recommendations to our central clinical practice committee to see what protocols or guidelines we can create or revise to help address the concerns. We will also have our central educators address this at their orientation presentations."

The JCAHO alert recommends the following:

  • Do not purchase non-intravenous equipment that is equipped with connectors that can physically mate with a female luer IV line connector.
  • Conduct acceptance testing for performance, safety and usability and, as appropriate, risk assessment, such as performing a failure mode and effect analysis, on new tubing and catheter purchases to identify the potential for misconnections and take appropriate preventive measures.
  • Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.
  • Recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival to a new setting or service as part of the hand-off process. Standardize this "line reconciliation" process.
  • Route tubes and catheters having different purposes in different, standardized directions (for example, IV lines routed toward the head; enteric lines toward the feet).
  • Inform nonclinical staff, patients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions.

Clinical staff should be instructed to never use "orphan" equipment, according to Debbie Benvenuto, BS, CRNI, education manager for the Norwood, MA-based Infusion Nurses Society. Also, infusion equipment and supplies should be stored separately from those indicated for enteral or respiratory care provision. "'Making do' or 'creative care practices' is not appropriate," she says.

Flagging all infusion sets and catheters should be a matter of daily routine for nursing staff, says Benvenuto. When accepting patients from one unit or another, or one shift to another, reconciliation of administration systems should be completed at the time of patient transfer and acceptance.

Performance should be measured during scheduled monitoring intervals, in addition to the times where an untoward event has occurred, says Benvenuto. "Historical problematic issues such as staffing, shift changes, or fluctuations in bed occupancy can be correlated with occurrences of untoward events, such as flawed parenteral administration practices," she says.

Consider doing a root cause analysis on tubing misconnection errors, says Benvenuto. "Whatever mechanisms the organization employs to identify, monitor, and track these events should be followed with process scrutiny and assessment activities," she adds.

Other effective interventions are ensuring good lighting, using luer-locking mechanisms, using dedicated infusion equipment that cannot be interchanged with other administration systems, requiring consistent nursing practices in conjunction with infusion-based policies and procedures, and use of dedicated infusion teams or experts in the delivery of infusion care.

You should also measure the number of near-miss events, issues surrounding staffing mix and adequate staffing levels, and validation of staff education and competencies, advises Benvenuto.

Share reports of both adverse outcomes and near misses with the Joint Commission, the U.S. Phamacopeia, the Food and Drug Administration, ISMP, and ECRI, recommends Benvenuto. This information also should be shared with all decision-makers and educators, health care clinicians, clinical practice committees, and risk management professionals at your organization.

"Both types of reporting events will be beneficial to health care organizations in the prevention of patient injuries and promotion of safety in the overall health care system," Benvenuto says.

[For more information, contact:

Debbie Benvenuto, BS, CRNI, Education Manager, Infusion Nurses Society, 220 Norwood Park South, Norwood, MA 02062. Telephone: (781) 440-9408 ext. 313. Fax: (781) 440-9409. E-mail:

Ann D. Law, RN, Outcomes Specialist, Covenant HealthCare, 1447 N. Harrison St., Saginaw, MI 48602. Telephone: (989) 583-4060. Fax: (989) 583-4822. E-mail:]