Worth Repeating….IV Tubing Misconnected to Tracheostomy Collar

While bathing a patient, a nursing staff member accidentally connected IV tubing from an insulin infusion to the port of a tracheostomy collar. (A tracheostomy collar secures the tube’s positioning once the surrounding balloon is inflated to minimize movement of the tracheostomy tube. Since a parenteral syringe is typically used for inflation, the port has a Luer connector.) Normally, patients wore gowns with sleeves that snapped closed. However, on the day of the error, this patient happened to be wearing a gown without snaps. In order to remove the gown, the staff member disconnected the patient’s IV insulin infusion and threaded it through the sleeve. When reconnecting the tubing, the nursing staff member connected the IV line to the Luer connection on the tracheostomy collar. Fluid began to further inflate the tracheostomy collar balloon, constricting the tube itself. The error was noticed when the patient began to decompensate and became cyanotic. The IV line was immediately disconnected from the tracheostomy collar, and approximately 30 mL of fluid was removed from  the balloon. Fortunately, the patient suffered no permanent harm. 

In our November 28, 2001 newsletter, we reported a similar error in which an IV solution was accidentally infused into the balloon of a tracheostomy collar, resulting in hyperinflation of the collar, constriction of the tube’s lumen, and an airway obstruction. High-volume, low-pressure collars are used to lower the long-term risk of tracheal injury, so they are compliant enough to accept large volumes of air—or fluid, in this case. The patient’s roommate alerted a nurse to the patient’s respiratory distress, and a code was called. The error was noticed when the code team was unable to inflate the lungs. The line was disconnected and the fluid was removed from the collar, but the patient died.

Several factors contributed to the 2001 error. In low, overhead lighting during the night, the nurse had mistaken the tracheostomy collar port as a triple lumen catheter port, especially since the unsecured tubing hung down at the same level as the tracheostomy collar tubing. Although the size of the tracheostomy collar line is distinctly thinner than regular IV tubing, triple lumen tubing is similarly thin like tracheostomy collar line. Furthermore, the connection ports on needleless tubing can appear very similar to the tracheostomy collar line–an interesting example of how even a powerful safety innovation—a needleless system—can lead to new, unexpected problems.

ISMP has received reports of numerous other inadvertent misconnections to balloon ports of various catheters and tubing, including:

• Accidental injection of drugs into an endotracheal tube collar during resuscitation efforts
• Drugs inadvertently delivered into the balloon inflation ports of Foley catheters and gastrostomy tubes.

These adverse events can be grouped into a larger class of errors labeled as, “Wrong tube, wrong hole, wrong connector.” Ideally, inflation and infusion ports should be incompatible, and interconnectivity should be impossible through product redesign. Until this occurs, consider the following error-reduction strategies.

Identify error potential through failure mode and effects analysis on existing medical tubing and when introducing new tubes, catheters, and connectors into a healthcare system. If possible, include an assessment of near novices doing multiple connections on manikins or in other simulated environments to promote the identification of, and focus on, high-hazard conditions. When possible, do not purchase tubing and connectors for non-intravenous functions that are compatible with IV tubing connectors.

Provide training to nurses, pharmacists, physicians, and respiratory therapists before using new tubes, catheters, and connectors. Include discussion about possible sources of errors identified during failure modeand effects analysis and steps to avoid these errors. When possible, include tubing misconnections in simulation training during orientation and annual safety competencies.

Affix labels on lines near insertion sites if the patient has more than one potential connection to a port of entry into the body (e.g., IV, arterial, umbilical, enteral, bladder, tracheostomy, drainage tubes).

Promote a consistent process for tracing all lines from the source (and infusion pump if used) to the connection port to verify attachments before connecting or reconnecting tubing, and/or administering drugs, solutions, or other products. Remind staff that, for patients with multiple tubes, situational awareness of each tube’s location and insertion site can be lost, especially if tubing is obscured by bedclothes and sheets.

Staff who are allowed to connect, disconnect, or reconnect medical tubing should be limited to those with professional healthcare training who are more likely to know and follow safety measures (such as tracing the line from the source to the point of entry), and are knowledgeable about the serious ramifications of misconnections. During orientation, include prohibitions to connecting/disconnecting medical tubing so those who should not be involved in these activities are aware of the mandate and reasons that require it.

Improve the environmental conditions under which medications are administered. Not surprisingly, we have often received reports of errors that have taken place at the bedside under poor lighting, particularly at night. Practitioners should adjust lights as needed for critical tasks (using flashlights, if necessary).

Monitor patients appropriately (e.g., vital signs, frequent observation, pulse oximetry, capnography cardiac monitoring) to detect an error quickly, and minimize the consequences of an error.