By Peggy McDaniel, BSN, RN. Peggy is an infusion practice manager and an occasional contributor to this blog.
by Lars Plougmann/via Flickr
The headline for a recent article in the New York Times caught my attention: U.S. Inaction Lets Look-Alike Tubes Kill Patients. For me, this conjured up pictures of giant tubes with teeth, wrapping around weak patients in their hospital beds and squeezing them. Although I knew exactly what the article was going to discuss, it bothered me that the tubes were given the reputation of being “killers.” Can tubes kill? I think not. Can they contribute to errors? Certainly.
The article explains that numerous patients have been harmed and some have died because clinicians have connected tubing that should not have been connected. These errors run the gamut from enteral feedings being given intravenously and blood pressure inflation devices being attached to IV lines, to administration of intravenous medications into epidural lines.
However, it remains the clinician’s responsibility to provide safe care.Repeated warnings.
The ISMP (Institute for Safe Medication Practices) and other groups have repeatedly warned against tubing misconnections, but errors still occur. Here is a recent ISMP reference to such errors. Their archives hold many more. A safety calendar distributed by the FDA in 2009 clearly documents examples of horrific misconnection errors. I find the illustrations frightening and thought provoking. I highly encourage you to take a look and share this with your peers.
The article points out that many groups, particularly in the U.S., have spent time pointing fingers at each other instead of demanding safer connections through manufacturing and regulatory means. I must agree that tubing connections should be made so that misconnections are impossible, but I remain firm in my belief that forcing function does not always ensure safety.
A culture issue?
Nurses and other clinicians are known for their ingenuity. This culture, with its “MacGyver attitude,” has historically been rewarded because nurses have been forced to “make things work” in response to our hectic work environment. Nurses are often expected to do more with less time and means—but somehow this must not compromise safety. Errors have been followed by punishment from both the employer and—in recent cases—the courts.
Even so, as hospitals seek to promote a culture of safety, errors are now seen as opportunities to learn and make changes. As health care becomes more transparent, with ever more focus on safety, many hope that the number of errors and their severity will decrease. Will improvement be driven by regulation, a shift in culture, or it a combination of these and other aspects? What are your experiences with misconnection errors? How can we best avoid them? What advice would you give a new nurse for avoiding these types of mistakes?
One of my favorite reminders to use when teaching a clinician a task is, “if it’s really difficult to do, it may not be the right thing to do.” I realize that this doesn’t always hold true, but my intention is to inspire my fellow clinicians to stop, take a moment to consider what they are doing, and then decide if it’s correct. Let’s all work together to promote a greater awareness of these errors. And yes, let’s also speak up and demand manufacturers and regulators to make the changes that will promote safer care.
This is really more than a few minutes of time- this is a design failure – these are not careless or innorant errors . Think of the Ford Pinto- would it suffice to say – just avoid getting rear ended ?
Humans will never be 100% vigilant 100% of the time – that is why a safety needs design redundancies to assist us in keeoing patients safe.
I’m a new RN, but in my last semester of nursing school, there was a patient in the unit with a blood sugar in the 300s on an insulin drip. He wasn’t responding to the insulin, and so they kept titrating it higher. When the orderly came to get the patient for some testing, she discovered the insulin had never been connected to the IV in the patient’s hand. The patient stated “I wondered why my bed was getting wet all night long,” but he never said anything to the nurse. I learned a lesson on that one, ALWAYS trace your lines from insertion point to the pump when you do your initial assessment!
Very chilling images on the FDA safety calendar. I’ll be sure to share this with my co-workers. Thanks for the great post.
I do wish we labeled oir lines some way. However, it onl takes 2 seconds to stop and think “is this supposed to go on that way”.