1. Alexander, Mary MA, RN, CRNI(R), CAE INS Chief Executive Officer

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I have noticed lately that the media have been spotlighting an issue of long-standing significance to infusion nurses: life-threatening tubing misconnections. Wrong-route administration errors occur as a result of tubing misconnections, a consequence of the near-universal use of Luer connectors. The devices were designed for ease of use by infusion professionals, yet that design makes it possible to inadvertently connect the wrong tubes and deliver the wrong medication or fluids. The Joint Commission reports that 9 cases of tubing misconnections involving 7 adults and 2 infants have been reported to its Sentinel Event database, resulting in 8 deaths and 1 permanent loss of function.1 US Pharmacopeia estimates that since 1999, there have been some 1,300 tubing misconnection cases in the United States.2

Figure. Mary Alexand... - Click to enlarge in new windowFigure. Mary Alexander, MA, RN, CRNI(R), CAE INS Chief Executive Officer

Although technology has been a tremendous help in addressing healthcare-related conditions, improper use or errors have led to avoidable fatal patient outcomes. In the past, nurses were considered ingenious or creative if they solved problems by finding other uses for a particular piece of equipment. In today's busy environment, however, those practices can be dangerous.


As hospitals, government agencies, and safe practice organizations sound the alarm about the growing number of tube misconnections, the search for viable solutions goes on. Some groups are focusing on educating healthcare professionals about how to avoid wrong-route administration errors; others are advocating completely new designs for equipment.


Although redesigning or reengineering products is not a simple task, making the changes and preventing harm or deadly outcomes is worth the time, effort, and resources. Some of the redesign solutions include:


* specific labeling of device ports to avoid connecting IV tubing to catheter cuffs or balloons


* standardization of color-coding for tubing and connections


* creation of physical barriers to eliminate the chance of interconnectivity between functionally dissimilar medical tubes and catheters2



In addition to product redesign to ensure that tubing is not compatible, some practices can be reinforced to prevent the misconnections:


* Placing and separating tubing on either side of the patient to reduce confusion and clutter


* Tracing tubing origins before reconnecting, placing, or infusing


* Educating all staff about this issue, considering the prevalence of the equipment within an entire facility (eg, what staff should do if tubing becomes disconnected, especially if there is no professional healthcare provider present)3


* Identifying error potential on existing tubing and when introducing new tubes, catheters, and connectors into a facility


* Improving the environmental conditions under which medications are administered (better lighting, for example)4



The delivery of healthcare is complex, but one response to the problem, which would have the added effect of making work less stressful, is to look at ways to eliminate and prevent errors that lead to adverse outcomes.


Medicine treats conditions and diseases that are not seen with the naked eye (eg, antibiotics administration for a bacterial infection). Tubing misconnections are visible problems. Infusion professionals should be able to have control and provide direction to address this problem as we continue to strive for excellence in care and patient safety.


Mary Alexander, MA, RN, CRNI(R), CAE INS Chief Executive Officer




1. Vecchione A. JCAHO warns of tubing errors. Healthy-System Edition, May 22, 2006. Accessed June 29, 2007. [Context Link]


2. Landro L. Tackling tube misconnections. Wall Street Journal [online]. June 27, 2007. [Context Link]


3. The Joint Commission. Patient safety solutions: avoiding catheter and tubing misconnections. May 2007;1(7). [Context Link]


4. Institute for Safe Medication Practices. IV tubing misconnected to tracheostomy collar. ISMP Medication Safety Alert!! June 14, 2007;12(12):1,3. [Context Link]