A recent issue of the Safety Matters publication at Brigham and Women’s Hospital in Boston told the story of how a tubing connection error occurred in the neonatal intensive care unit (NICU), which caused intravenous fluid to damage the baby’s skin at the wrist.
As part of a routine tubing change, a nurse intended to separate the arterial tubing from the umbilical vein tubing, which was infusing liquid nutrition and intravenous medications, by running them through separate portholes in the incubator. After a shift change, another nurse realized the liquid nutrition tubing mistakenly was connected to the arterial tubing.
The incident left the newborn with a scar on his wrist but no other harm. The Safety Matters account explains that the error was not properly disclosed to the parents, who learned of the incident days later when it was mentioned in passing. A main theme of the story told in Safety Matters was the parents’ disappointment and how the lack of proper disclosure caused them unnecessary stress. The parents considered moving the baby to another hospital for care, but they ultimately stayed with Brigham and Women’s.
The story goes on to dissect what went wrong with the tubing error and how the clinicians failed to follow the hospital’s protocol on disclosure.
“There was also no documentation of the initial conversation with the covering evening shift physician in the Baby Oliver’s chart, so the primary team was unaware that the parents did not know about the error. They realized this at the family meeting, when the parents reacted with surprise,” the newsletter explains. “The covering physician and team had not followed the appropriate disclosure protocol, which requires documentation of the disclosure conversation including: names of participants; the date, time, and communication to the primary team; and that the parents had been informed of the error.”
The story concludes with a rundown of what Brigham and Women’s is doing to prevent a recurrence of the problem, including working with a vendor to obtain tubing that is designed to prevent the type of connection error in this case. The hospital also re-educated nurses about the potential for this type of error. The newsletter also included summaries of the handoff process that can reduce errors at shift change, and the hospital’s disclosure and apology process. The Safety Matters newsletter is available online at http://tinyurl.com/j3kdr3g.
