Preventing Misconnections of Lines and Cables

October 6, 2015 | Healthcare Risk, Quality, & Safety Guidance

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The numerous lines and cables that link patients to medical devices or medical devices to each other can create the potential for misconnection. Patients are often connected to several devices used for diagnostic, therapeutic, or monitoring purposes; for example, a patient in a coronary care unit may have as many as 40 connections to various devices (ANSI/AAMI/ISO). Such visual clutter—added to the stress, fatigue, and distraction so typical of the clinical environment—can make the risk of misconnecting a tube or catheters to the wrong device more likely (GEDSA "Panel").

Misconnections are a well-known but underreported problem (GEDSA "Panel"). Serious patient injury or death can result when a connection is made to the wrong device, such as if a liquid intended for delivery into the stomach via an enteral feeding tube is instead delivered into the bloodstream through an IV catheter. Indeed, the administration of enteral fluids intravenously has been described as "pouring concrete down a drain" and can cause death (Harris). Clinical literature and event reporting databases—such as the U.S. Food and Drug Administration's (FDA) MAUDE (Manufacturer and User Facility Device Experience) database, ECRI Institute's Problem Reporting System, and the ECRI Institute PSO database—cite numerous cases of misconnections that have resulted in patient injury or even death.

Misconnections vary greatly in type and in the severity of their outcome. Below are some case reports describing a number of potential misconnection hazards, organized according to the types of lines or cables involved. *

* Note that in addition to the misconnections listed here, cable/liquid and cable/gas misconnections are also theoretically possible. However, they are rare and are not addressed in this guidance article.

Cable misconnections. Cables are often attached to patients for monitoring purposes or used to connect medical devices to power sources. Cable misconnections can lead to adverse events, including patient burns and equipment damage. Electrocution is also possible,...

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