Problems persist with life-threatening
From the June 17, 2004 issue
In our June 12, 2003 newsletter, we reported several cases
in which the tubing from a portable blood pressure monitoring
device was inadvertently connected to the patients IV
line in one case, leading to a fatal air embolism.
In our September 4, 2003 issue, we wrote about an inadvertent
connection of an air supply hose from a sequential compression
device (SCD), also referred to as intermittent pneumatic compression,
to a needleless IV tubing port. In that case, the SCD was
turned off and the misconnection was found before any harm
|Figure 1. Tube delivering oxygen fell off
nebulizer.||Figure 2. The oxygen tubing was connected
to a Baxter Clearlink needleless port.
Sadly, we recently learned about another tragic error involving
the connection of oxygen tubing to a pediatric patients
IV line. The child had been receiving medication via a nebulizer
to treat asthma. While still attached to a wall outlet, the
oxygen tubing (AIRLIFE, from Allegiance Healthcare
Corporation) became disconnected from the nebulizer fluid
chamber (see Figure 1 in the PDF version of the newsletter).
Later, a staff member accidentally reconnected the oxygen
tubing to the injection port on a Baxter CLEARLINK
Needleless Access System IV tubing Y-site.
While oxygen tubing does not have a Luer connector, Baxters
investigation into this event confirmed that such a connection
is possible with their Clearlink valve (with oxygen tubing
encompassing the Y site), albeit with excessive force (see
Figure 2 in the PDF version of the newsletter). According
to the FDA report on this event, the oxygen tubing disconnected
from the IV tubing in seconds, but not before the pressure
of the compressed oxygen supply forced the needleless valve
open and allowed air into the tubing. The child died instantly.
Baxter has since issued a safety alert advising of this hazard.
However, the May 13, 2004, alert was sent only to directors
of nursing, so others who need to know, including respiratory
therapists, may have missed it.
Although these types of misconnections might be uncommon,
the risk of a similar tragic event persists and is likely
to be present in most hospitals including yours! Baxter
is exploring modifications to the Clearlink valve to prevent
the potential for a recurrence elsewhere. Allegiance has also
redesigned the specific oxygen tube to nebulizer connection
with hard plastic to reduce separation. Still, we tested a
variety of additional needleless devices that also accommodated
oxygen tube connectors. Right now, oxygen tubing could very
well connect to your needleless or standard IV tubing, including
systems from Alaris, Baxter, B. Braun, BMP, Inc., Catheter
Innovations, Clave, and Hospira (formerly Abbott). Clearlink
is a clear needleless system, similar to some oxygen tubing,
but the color on other needleless systems may not be a deterrent.
Additionally, all medical gases and most fluids are clear,
making it virtually impossible to distinguish between them
when observed through transparent medical tubing. As in this
case, many medical tubing attachment sites look
quite similar, further increasing the risk of an error. With
typical oxygen flow rates in liters per minute, a fatal pneumatic
misconnection would require only seconds.
The best solution lies with eliminating interconnectivity
between various medical tubings. The Association for the Advancement
of Medical Instrumentation (AAMI) offers a publication (HE-74,
Human factors design process for medical devices) that provides
human factors engineering guidance to aid in the proactive
testing of tubing interconnectivity in realistic settings.
However, we are unaware of any specific domestic or international
standards organization looking at mandatory standards for
Take the time to review the medical equipment used in your
facility to identify the potential for misconnections to IV
tubing. Educate all staff, including non-clinical employees
who work in patient care units, about this hazard, perhaps
using storyboards to communicate the point effectively. Before
tubing is connected or reconnected to a patient, require staff
to completely trace it from the patient to the point of origin
for verification. Appropriately labeled IV lines could help
alert staff if they are about to access that line accidentally.
Also identify all types of staff in your organization who
might connect, disconnect, or reconnect various forms of tubing
(including IV tubing) attached to patients (e.g., technicians
who work in diagnostic units, transport staff, nursing assistants,
students, physicians), and consider whether this task falls
within a safe and acceptable scope of practice. Certainly,
trained licensed practitioners can inadvertently connect the
wrong tubing to an IV line. However, untrained staff (e.g.,
ancillary personnel, medical and nursing students) are less
likely to know and follow safety measures (such as tracing
the line from the patient to the point of origin), or to be
knowledgeable about the serious ramifications of misconnections.
In fact, many unlicensed, untrained staff may disconnect or
reconnect various tubing, or be asked inappropriately to perform
specific tasks such as turning off pumps or pressing the PCA
button before patient transport. Include prohibitions for
these tasks during orientation, and when possible, offer new
ancillary staff practice in turning down requests to connect
or disconnect medical tubing.