Patient Safety Tip of the Week
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
While statistics are important in
patient safety, it is stories that get people’s attention. Perhaps the most dramatic
story I ever heard was from a nurse involved in an incident where a child was
given Bicillin intravascularly, causing a death. That nurse’s world was turned
upside down by that event. The irony is that our system failed her. Our system
put her and many other nurses and doctors and patients in a position where a
substance could be inadvertently given via the wrong catheter/route.
It has been over a year since Joint
Commission issued a Sentinel Event
Alert about catheter misconnections and
administering substances via routes they were not intended to be administered.
Recently, the issue has received considerable attention again.
Last month, the Wisconsin State Journal had a multipart
series on medical errors and incidents and focused especially on cases of
catheter misconnections or administering substances via the wrong route. That
followed a fatal case last year in which a nurse had criminal charges filed
after giving a drug intended for epidural anesthesia intravascularly. And there
are previous similar cases where criminal charges were filed against nurses in
cases where the system made them vulnerable to be at the “sharp” end of an
unfortunate incident.
The Joint Commission’s Sentinel
Event Database had nine cases at the time it issued its Sentinel Event Alert in
April 2006. But the problem of catheter misconnections and wrong route
drug/fluid administration is much more common. The US Pharmacopoeia reporting
system (a voluntary reporting system) has over 1200 reports of cases in the
past nine years in which a substance intended for one catheter was
inadvertently administered into another catheter. The cases involve almost any
catheter you can think of (substances intended for feeding tubes being given
intravenously or via dialysis catheter, intravenous medications being given
intrathecally, hypertonic intravenous contrast agents being given intrathecally
for myelography, bladder irrigation solutions being given intravenously,
intramuscular medications like Bicillin being given intravascularly, IV fluid
being injected into a tracheostomy cuff, blood pressure cuffs being hooked up to
IV lines, and many more examples).
ISMP/FDA Medication Safety Alerts
have been issued at least as early as 2001, some of which include video
presentations .
One of the salient problems, of
course, is that the design of the systems allows 2 things to be connected that
were never intended to be connected. The most successful safety interventions
in any industry are forcing functions, that is designs that force someone to do
something or not to do something. This particular issue is one that should be
amenable to use of such forcing function solutions.
A major problem is use of the luer
connections in the various types of tubing, catheters, or syringes. Good design
would prevent a feeding tube or syringe with feeding solution from being
physically connected to an IV catheter. Many facilities have moved away from
purchasing any feeding systems that utilize luer connections. One of the
biggest barriers has been getting the device manufacturing industry to come up
with standards for connections on the various devices.
European healthcare organizations
seem to be a little farther along in addressing the issues. In fact, the
National Patient Safety Agency in the UK just issued a Patient Safety Alert on
March 28, 2007 on “Promoting
safer measurement and administration of liquid medicines via oral and other
enteral routes” . This addresses design of
equipment and labeling of tubes and syringes.
But there are multiple other
contributing factors noted by both Joint Commission and ISMP. One of the
biggest problems is that the various catheters and tubes may be in close
proximity to each other, without clearcut labeling or other identification.
Color coding of various lines/devices has been suggested but without a standard
across facilities use of color coding could lead to unintended consequences.
When color coding is not feasible, it may be possible to flag high risk
medications by other means, such as wrapping them in foil. It is imperative
that one always trace a tube or catheter or line from the patient to the point
of origin before connecting any new device, line, infusion or other substance.
This should always be done in proper lighting (many times a caregiver does not
want to wake a sleeping patient so makes the connection in a dimly lit room).
The issue needs prominent attention
in education and training sessions and should be part of annual competency
inservices/evaluations. Including “lines and connections” may be an important
part of change of shift communications or other handoffs. Importantly,
facilities should make monitoring of these systems a priority. It would be a
good process to add to your “patient safety walk rounds” and is an excellent
process to conduct FMEA (failure mode and effects analysis) around.
Keep your eyes and ears open. We
will likely see and hear more about this issue over the next year.
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