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Another risk of IV misconnections

From the October 6, 2005

The V.A.C. INSTILL SYSTEM by KCI is a wound healing system that facilitates automated delivery of topical solutions to wound sites. While very different from an infusion pump, the device is programmed to deliver a desired rate of infusion; but it lacks protection from gravity free-flow if the tubing is removed. Unfortunately, the device is designed to accommodate IV tubing to deliver the topical solution (e.g., Dakin’s solution, silver nitrate solution, SULFAMYLON [mafenide acetate]). Thus, one could inadvertently attach the “IV” tubing intended for the V.A.C. to an IV port. Previously reported misconnections of seemingly dissimilar tubing (e.g., blood pressure, oxygen, and air supply tubing) to IV ports should serve as a reminder that such an event is possible. In fact, there are a few additional conditions that heighten the risk of connecting the V.A.C. tubing to an IV line. First, most V.A.C. topical solutions are prepared in “IV” bags, so bags and tubing look similar. Next, the device provides a detachable “IV” pole (as described in product literature) on which to hang the “IV” bag of solution. Finally, the device is indicated for recalcitrant wounds, so it’s used infrequently. Thus, staff may be unfamiliar with the device and unaware of the risk of misconnections. Furthermore, there will be no protection from gravity free-flow if the tubing is erroneously attached to an IV site and is removed from the device. The reporting nurse has asked KCI to develop specific tubing that connects only to their equipment. Meanwhile, prepare topical solutions in a container dissimilar to typical IV solutions, such as a 500 mL bottle. Special adapter caps for the irrigation solutions will accommodate IV tubing for use with the V.A.C. Instill System. Misconnections are also less likely if you label all lines; affix bold cautionary labels to topical solutions; physically trace all lines from the source solution to the port of insertion; and require an independent double check before initial use of the device, or when replacing bags of solutions.

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