IV tubing misconnection errors most commonly occur when a nurse negligently connects one end of a tube or catheter to the wrong device. For example, connecting a feeding tube to an IV catheter will result in the intravenous infusion of liquid food, a tubing misconnection error which can have fatal consequences. Hospitals have known about these dangers for years. As far back as April, 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) sounded the alarm by issuing a Sentinel Event Alert (SEA) entitled Tubing Misconnections-A Persistent and Potentially Deadly Occurrence. JCAHO offers many suggestions designed to help hospitals reduce the incidence of injury. Some are simple, practical steps which are easy for hospitals to incorporate into training and every day policies and procedures. They include:
- Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.
- Recheck connections and trace all patient tubes and catheters to their sources upon the patient’s arrival to a new setting or service as part of the hand-off process. Standardize this “line reconciliation” process.
- Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially important in the care of neonates.
- For certain high-risk catheters (e.g., epidural, intrathecal, arterial), label the catheter and do not use catheters that have injection ports.
- Emphasize the risk of tubing misconnections in orientation and training curricula.
- Identify and manage conditions and practices that may contribute to health care worker fatigue, and take appropriate action
Unfortunately, tubing misconnections still occur due to nursing error often caused by poor lighting in the patient’s room at night, fatigue, inadequate training, rotating shift work, time pressure, attempts to use short-term memory recall for large amounts of information, or just poor nursing practice and technique. All of these are avoidable by adherence to the proper standard of care when connecting, reconnecting or changing tubing connections. Nevertheless, mistakes still occur and often lead to death or serious injury.
If you or someone you know has suffered injury or loss on account of an IV tubing misconnection error that was caused by nursing negligence or hospital neglect, contact one of the attorneys at Burnside Law Firm LLP for a free initial consultation to learn more about your legal rights. Often times, legal remedies are available to recover for past and future medical expenses, pain and suffering and the other losses you have suffered.
Contact us by providing the details of your case in the attached e-mail contact form, or by calling at (706) 432-8320.
