Nurse's misdemeanor incident reveals potential dangers of modern technology

Want to avoid the top hazards? Follow this advice

The nurse had worked almost 17 hours in an "intense double shift" and slept less than six hours before starting her third shift, according to the Risky Business web site.1 Julie held two infusions bags. They were the same size, same shape, and had identical connectors.

Because she had difficulties using the bar code scanning device on the same types of clear infusion bags during her two previous shifts, she didn't try to use the device. Julie inadvertently mixed up the antibiotic bag and epidural bag, and the epidural drug was delivered through the patient's IV, the web site says. Her mistake resulted in the death of a young mother, it says. When the mistake was discovered, Julie collapsed, then was admitted to her hospital's psychiatric unit, the web site says.

Her nightmare wasn't over. In the following weeks, she was fired with no severance pay and was criminally charged. When she returned to receive pastoral care at her hospital, she was told not to return to the property, the web site says. Due to the legal costs, she accepted a plea bargain of two misdemeanors and did not have to serve a jail sentence. The board of nurses investigated and allowed her to practice again within one year. "However, her life will never be the same after having made a fatal human error that was predisposed by systems failures and human factors," the web site says. "Subsequently, she has been embraced by leaders of the patient safety community to help make her story a learning case that can prevent harm to patients, caregivers, and our hospitals."

Julie now educates healthcare providers about how to avoid medical errors. She also is working with manufacturers so connections are specific for certain type of medications. Her story highlights the potential danger with medical technologies, including Luer misconnections. ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care, recently named Luer misconnections as one of the top 10 technology hazards for 2011.2 [See full top 10 list, below. To access the full report, see resource box, below. Same-Day Surgery first reported on the top 10 technology hazards in the Dec. 3, 2010, issue of Same-Day Surgery Weekly Alert. To subscribe to this free weekly ezine, contact customer service at or (800) 688-2421.]

Top 10 Hazards for 2011
  • Radiation overdose and other dose errors during radiation therapy
  • Alarm hazards
  • Cross-contamination from flexible endoscopes
  • High radiation dose of CT scans
  • Data loss, system incompatibilities, and other health IT complications
  • Luer misconnections
  • Oversedation during use of PCA infusion pumps
  • Needlesticks and other sharps injuries
  • Surgical fires
  • Defibrillator failures in emergency resuscitation attempts

Source: ECRI Institute, Plymouth Meeting, MA.

Luer misconnections occur when two like connectors from two types of devices or lines allow you to make a misconnection. "Ambulatory surgery centers should not have any noninvasive blood pressure monitors that have Luer connections on them," says Jim Keller Jr., MS, vice president of health technology evaluation and safety at ECRI Institute. "As a routine practice, the clinical staff should trace the line to its source," Keller says.

With surgical patients, the IV access often is not very visible, sources point out. "It may be under the drape," says Jane A. Kusler-Jensen, RN, BSN, MBA, CNOR, executive director for Orthopedic Hospital of Wisconsin, part of Columbia St. Mary's Healthcare System, Milwaukee, WI. Among several prior positions, she has been administrator of Physicians Plus Surgery Center in Madison, WI, and nurse manager at Surgicenter of Greater Milwaukee. "If you're counting on Luer connections as means of administering medications, those lines and those Luer connections need to be labeled with what medications are going through there so you are not giving medication in manner unsafe for the patient," Kusler-Jensen says.

You also can use color coding or another type of mechanisms to make sure you're administering the right medications through the right types of lines, she says.

ECRI Institute recommends the following:

  • Provide periodic training about misconnection prevention to all patient care staff.
  • Prohibit the use of adapters, which can permit the connection of two components that normally wouldn't mate and that often shouldn't be connected, such as two female Luer connectors. Exceptions should be carefully reviewed and justified, and measures should be implemented to ensure that the adapters will not be misused.
  • Review purchasing policies to ensure that, whenever possible, only products with misconnection safeguards are purchased.
  • Identify and manage conditions and practices that might contribute to healthcare worker fatigue.
  • In addition to requiring that staff trace all lines back to their origin before making connections, require them to recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival in a new setting or service as part of the handoff process.
  • Label certain high-risk catheters, such as epidural, intrathecal, and arterial catheters, so that staff can clearly see that they are making a connection to one of these devices. (For information on ECRI's identified hazard with PCA pumps, see story, below. For information on hazard from cross-contamination from flexible endoscopes, see below.)


  1. Risky Business. Video Description: Imagine Being Charged for Manslaughter for a Drug Error. Accessed at
  2. ECRI Institute. Top 10 health technology hazards for 2011. Health Devices 2010; 39. Accessed at


To access the free full report of the top 10 technology hazards, go to To view the free video, go to

Don't get caught with PCA pump hazards

A top 10 technology hazard identified by ECRI Institute1 has been in the news lately: oversedation during use of patient-controlled analgesic (PCA) infusion pumps.

A study examined critical incident reports from 2002-2009 at three tertiary care hospitals to determine whether a safety intervention by a multidisciplinary panel reduced adverse PCA drug events.2 There were 25,198 patients and 62 errors before the safety interventions, with 21 errors involving programming the wrong drug concentration. Improper setup of IV tubing also was a common error.

The safety interventions included new PCA pumps (Alaris PCA module; CareFusion Corp., Toronto, Ontario, Canada) that were easier to program and had "soft" and "hard" medication limits. The interventions also included preprinted physician orders, an independent nurse double-check of the PCA program settings incorporated into the orders, a policy requiring nurses to review PCA settings during each shift and on shift handover, the implementation of a mandatory critical incident reporting program, and nurse education on the use and setup of the new PCA pumps. The incidence of PCA errors was less than 1% after the safety interventions, according to lead study author James E. Paul, MD, MSc, FRCPC, associate clinical professor at McMaster University, Hamilton, Ontario.

The problem with PCA pumps has been recognized by the Food and Drug Administration (FDA), which announced an initiative in April 2010 to address infusion pump safety, including PCA pumps.

PCA pumps are more of a risk in the ambulatory surgery setting because they're aren't a "high frequency item," says Jane A. Kusler-Jensen, RN, BSN, MBA, CNOR, executive director for Orthopedic Hospital of Wisconsin, part of Columbia St. Mary's Healthcare System, Milwaukee, WI. "For those patients that might be staying a length of time and having a PCA pump, make sure you're familiar with functioning of the pump and make sure it's functioning correctly," Kusler-Jensen says. At her facility, staff members update their skills with the pumps annually at a skills fair with a demonstration/return demonstration of its use, she says.

The biggest problem with oversedation during use of PCA infusion pumps is respiratory depression, says Jim Keller Jr., MS, vice president of health technology evaluation and safety at ECRI Institute. "This may be caused by incorrect dose or concentration," he says. Keller says the potential causes include being busy and not carefully looking at other medications the patient might be taking "where two of them combined may cause a propensity for the patient to have respiratory depression," he says.

Double check the dose that's ordered and programmed, Keller says. "The ordered dose could be incorrect, so check the prescription, and then once it's programmed into the pump, make sure it matches the order," he says. Some pumps have a dose error reduction feature, Keller points out. However, oversedation also can occur when a patient receives the correct dose, but responds differently than expected, ECRI Institute points out. For example, patients with conditions such as sleep apnea might be at higher risk for respiratory depression.

The Anesthesia Patient Safety Foundation (APSF) recommends that patients who are on PCA therapy be monitored. Keller says, "It's truly important for the surgery center to make sure they have an effective monitoring program in place specifically to monitor the patient's conditions, particularly the respiratory depression by pulse oximetry monitoring and capnography." Improper assessment of patients on PCA therapy can mask the symptoms of oversedation, ECRI points out. For example, the caregiver might arouse the patient before checking the patient's vital signs.


  1. ECRI Institute. Top 10 health technology hazards for 2011. Health Devices 2010; 39. Accessed at
  2. Paul JE, Bertram B, Antoni K, et al. Impact of a comprehensive safety initiative on patient-controlled analgesia errors. Anesthesiology 2010;113:1427-1432. Doi: 10.1097/ALN.0b013e3181fcb427. Accessed at

Avoid cross-contamination from flexible endoscopes

Ensuring staff are trained to properly clean and disinfect flexible endoscopes and are adhering to protocols is "an area that an be fraught with problems because the scopes are channels; they can be difficult to clean," says Marcia Patrick, RN, MSN, CIC, director infection prevention and control at MultiCare Health System, Tacoma, WA, and board member of the Association for Professionals in Infection Control and Epidemiology (APIC).

Patrick isn't alone in her concerns. Cross-contamination from flexible endoscopes has been named one of the top 10 health technology hazards for 2011 by ECRI Institute.1 ECRI offers these suggestions:

• Ensure that documented protocols are readily available and that staff are trained and follow them. Periodically repeat training.

"It's important that all steps are followed, each and every time," Patrick says. Ensure that every staff person who cleans and disinfects endoscopes is fully competent and that a supervisor who understands the process monitors their practices, she says.

• Have a model-specific reprocessing protocol for each flexible endoscope. Refer to the user manual and consult the endoscope or reprocessor manufacturer to identify unique requirements (such as cleaning procedures, channel adapters) to address in each protocol. Repeat for each new model, reprocessor, or equipment and accessories.

"The cleaning procedure is critical," Patrick says. MultiCare requires ambulatory/endoscopy facilities to post the cleaning procedure, Patrick says. Some manufacturers have posters. "If they don't have it, write it up according to the manufacturer, laminate the instructions, and post above the cleaning area," she says.

Staff might feel pressured by quick turnaround time, Patrick points out. "It's important that person doing the cleaning have a resource right in front of them," she says.

Often the least knowledgeable person is the one who ends up cleaning the scopes, Patrick says. Several years ago, she heard about a cleaning tech who went on vacation. His replacement wasn't thoroughly rinsing the scopes. A number of endoscopy patients subsequently developed colon irritation and diarrhea. Rinsing is "a procedural step," Patrick says. "It needs to be clearly communicated to staff."

Consider limiting scopes to one manufacturer, as new scopes require training, she points out.

• Periodically review protocols to ensure that they are clear and comprehensive and that they reflect the current environment. Verify that they don't include obsolete workflows or equipment/chemicals that are no longer in use.

• Ensure protocols address and document all steps in adequate detail, from precleaning at the treatment site to safe, aseptic transport back to the treatment site.

• If your facility uses a reprocessing unit, such as an automated endoscope reprocessor (AER), a liquid chemical sterilization system, or a gas plasma sterilizer, ensure the following:

— Endoscopes and related equipment in your inventory are compatible with the reprocessor and its disinfecting/sterilizing agent.

— Appropriate channel adapters are available to connect the endoscope to the reprocessor, and staff members are familiar with the correct endoscope/connector combinations. "The correct connectors have to be there, and it has to be connected correctly," Patrick emphasizes." Otherwise, the disinfectant won't go through all the different channels and will leave it non-disinfected."

— Staff members are familiar with and adhere to reprocessor maintenance schedules, including the periodic replacement of particulate and bacterial filters.

Keep records of preventive maintenance, and ensure someone is responsible and it is occurring on schedule, Patrick says. You will have an assigned work order or a bill from a vendor, she points out. "Those should be kept on file so you can demonstrate that in fact it is being done," Patrick says. (For a reprocessing toolkit, see story, below.)


  1. ECRI Institute. Top 10 health technology hazards for 2011. Health Devices 2010; 39. Accessed at

New toolkits target reprocessing

Ambulatory Surgery Centers (ASCs) interested in learning more about the best practices for reprocessing endoscopes and reprocessing single-use devices can download free toolkits provided by the Ambulatory Surgery Center Quality Collaboration (ASC QC). The Endoscope Reprocessing Toolkit ( and the Single-Use Device Reprocessing Toolkit ( are part of the ASC QC's ASC Tools for Infection Prevention (ASC TIPs) initiative and the last in a series of free infection prevention resources now available online.

ASC QC introduced its ASC TIPs series with a Hand Hygiene Toolkit posted on its web site last June. The other toolkits available on that web site ( focus on safe injection practices, point-of-care devices, and environmental infection protection. Basic and expanded versions of all six toolkits are available. The basic versions include essential resources such as Medicare surveyor worksheets and policy guides. The expanded versions include assessment tools, implementation aids, training materials, monitoring tools, workplace reminders, and guidelines from leading authorities.