IV connection to tracheostomy
cuff inflation port reflects larger problem
From the November 28, 2001 issue
PROBLEM: A few weeks ago, we heard about the unfortunate
death of a patient whose IV tubing had been connected to his
tracheostomy tube cuff inflation port. The patient had both
a Shiley low-pressure tracheostomy tube and a triple lumen
central IV line catheter in place. Someone accidentally attached
an IV fluid line to the tracheostomy cuff pilot line (used
to inflate the balloon and regulate pressure), instead of
the intended port on the triple lumen catheter. Once the IV
infusion pump was turned on, the cuff continued to inflate
with fluid causing the tracheostomy tube to become obstructed.
A roommate called a nurse to alert her to the patient's respiratory
distress, but the patient eventually arrested. The obstruction
was noticed when the code team was unable to inflate the lungs.
The line was disconnected and fluid and air were removed from
the cuff, but the patient did not survive.
It may be hard to understand how one could mistake a tracheostomy
cuff tube with a triple lumen catheter, but several underlying
factors allowed this error to happen. The patient had just
been transferred from critical care to a medical unit where
tracheostomy tubes were infrequently encountered and patients
were not routinely monitored with pulse oximetry or capnography
to quickly detect problems. Dim lights at night also played
a role. It's likely that the infusion was connected without
additional light to avoid waking the patient or his roommate.
The risk of error was heightened because the patient's triple
lumen catheter was not secured, so the tubing hung down at
the same level as the tracheostomy cuff tubing. Although the
size of the tracheostomy pilot line is distinctly thinner
than regular IV tubing, triple lumen lines also are thin.
Furthermore, the connection ports on needleless tubing can
appear very similar to the tracheostomy pilot line - an interesting
example of how an apparent win-win safety innovation (needleless
system) can lead to new, unsuspected problems. And the IV
tubing fit into the pilot line. The port on the pilot line
is compatible with slip tip and Luer lock syringes (and therefore
IV tubing) for easy inflation or deflation. Finally, because
high-volume, low-pressure cuffs are used to lower the long-term
risk of tracheal injury, they are compliant enough to accept
a massive volume of air - or fluid in this case. Unfortunately,
the infusion pump provided sufficient pressure to overinflate
the cuff, but it did not alarm or stop from the high pressure
needed to do so.
SAFE PRACTICE RECOMMENDATION: We've received a similar
report of accidental injection of drugs into an endotracheal
tube cuff during resuscitation efforts. We've also heard of
other unusual cases such as attaching oxygen to a total joint
drainage system, which resulted in a patient's death from
a gas embolism. But before you think these rare occurrences
can be prevented by simply encouraging staff to be careful,
keep in mind that they are symptomatic of a larger class of
errors that we've heard labeled as, "Wrong tube, wrong hole,
wrong connector." When viewed in this light, there's much
that should be done to prevent these errors collectively.
Healthcare providers should:
Healthcare regulators and manufacturers also must play a role
in solving this problem. Standard-setting groups must gain consensus
on issues surrounding Luer lock connectors. Although careful
testing of possible new error pathways is necessary, manufacturers
must find ways to make problematic connectors incompatible with
each other. Some testing and redesign of IV infusion pumps might
be in order so that a high-pressure alarm would alert staff
if a similar incident happened. FDA must also take action. Perhaps
tracheostomy tube manufacturers should be required to adopt
a universal method of differentiating cuff inflation ports (to
look/feel different) from IV ports, especially since compatibility
with existing syringes is necessary for safe use. Practitioners
can help spur action by reporting events to the USP-ISMP Medication
Errors Reporting Program (800-233-7767 or www.ismp.org). Experience
has shown that the more evidence we have to show manufacturers,
the greater the likelihood of design changes.
- Identify error potential through failure mode and
effects analysis when introducing new tubes, catheters,
and connectors into a healthcare system.
- Provide training to nurses, pharmacists, physicians,
and respiratory therapists before using new tubes, catheters,
and connectors. Include discussion about possible sources
of error identified during failure mode and effects analysis
and steps to avoid these errors.
- Affix labels on lines near insertion sites when
the patient has more than one potential connection to a
port of entry into the body (IV, arterial, umbilical, enteral,
bladder, tracheostomy, drainage tubes, etc.).
- Trace all lines from the source (and infusion pump
if used)to the connection port to verify attachments before
administration of drugs, solutions, or other products.
- Independently double-check all line attachments
with two practitioners if infusing high alert medications
or solutions, or if administering products to high-risk
- Monitor patients (e.g., vital signs, frequent observation,
pulse oximetry, capnography, cardiac monitoring, etc.) appropriately
to assess the effects of medications, detect an error quickly,
and minimize the consequences of an error.