WHO Collaborating Centre for Patient Safety Solutions Aide Memoire

Avoiding Catheter and Tubing Mis-Connections

Patient Safety Solutions

| volume 1, solution 7 | May 2007

▶ Statement of Problem and Impact:

Tubing, catheters, and syringes are a fundamental aspect of tient. Though these errors are highly preventable and can often
daily health care provision for the delivery of medications and be easily averted, multiple reports of patient injury and death
fluids to patients. The design of these devices is such that it is from such wrong route medication errors indicate that they oc-
possible to inadvertently connect the wrong syringes and tubing cur with relative frequency (1-7). This includes erroneous ad-
and then deliver medication or fluids through an unintended ministration routes for aerosols.
and therefore wrong route. This is due to the multiple devices
In the United States of America (USA), nine cases of tubing
used for different routes of administration being able to connect
misconnections involving seven adults and two infants have
to each other. The best solution lies with introducing design fea-
been reported to the Joint Commission’s Sentinel Event data-
tures that prevent misconnections and prompt the user to take
base, resulting in eight deaths and one permanent loss of func-
the correct action.
tion (8). Similar incidents have been reported to other agen-
Other causes or contributing factors include: cies, including the ECRI Institute, the United States Food and
Drug Administration, the Institute for Safe Medication Practices
▶ Luer connectors. Used almost universally in a variety of
(ISMP), and the United States Pharmacopeia (USP). Data from
medical applications to link medical devices, including
these groups reveal that misconnection errors occur with sig-
fluid delivery (via the enteral, intravascular, spinal, and
epidural routes) and insufflation of gas (in balloon cath- nificant frequency and, in a number of instances, lead to deadly
eters, endotracheal cuffs, and automatic blood pressure consequences (9,10).
devices), they have been found to enable functionally The most common types of tubes and catheters involved in the
dissimilar tubes or catheters to be connected. cases reported to the Joint Commission are central venous cath-
▶ Routine use of tubes or catheters for unintended pur- eters, peripheral IV catheters, nasogastric feeding tubes, per-
poses. This includes using intravenous (IV) extension cutaneous enteric feeding tubes, peritoneal dialysis catheters,
tubing for epidurals, irrigation, drains, and central lines tracheostomy cuff inflation tubes, and automatic blood pres-
or to extend enteric feeding tubes. sure cuff insufflator tubes. Examples include specific miscon-
nections involving an enteric tube feeding into an IV catheter
▶ Positioning of functionally dissimilar tubes used in pa-
(four cases); a blood pressure insufflator tube connected to an
tient care in close proximity to one another. For exam-
IV catheter (two cases); and the injection of intravenous fluid
ple, use of an enteral feeding tube near a central intra-
venous catheter and tubing. into a tracheostomy cuff inflation tube (one case).
In the United Kingdom, between 2001 and 2004, there were
▶ Movement of the patient from one setting or service
three reports of death, and from 1997 to 2004 there were four re-
to another.
ports of harm or near misses following wrong route errors when
▶ Staff fatigue associated with working consecutive shifts. oral liquid medicines, feeds, and flushes were administered in-
Tubing and catheter misconnections can lead to wrong route travenously (11). A review of the National Reporting
medication errors and result in serious injury or death to the pa- and Learning System in the United Kingdom identi-
fied 32 reported incidents in which oral liquid medicines 2. Incorporate training on the hazards of misconnecting
were administered by the intravenous route, seven incidents tubing and devices into the orientation and continuing
in which epidural medication was administered via the professional development of practitioners and health-
intravenous route, and six incidents in which intravenous care workers.
medication was administered via the epidural route from
3. Promote the purchasing of tubes and catheters that are
1 January 2005 to 31 May 2006.
designed to enhance safety and to prevent misconnec-
tions with other devices or tubes.
▶ Associated Issues:
While various approaches to preventing catheter miscon-
▶ Looking Forward:
nection and wrong route administration have been sug-
1. Physical barriers (e.g. incompatibility by design)
gested, meticulous attention to detail when administering
medications and feedings (i.e. the right route of administra- should be created to eliminate the possibility of inter-
tion) and when connecting devices to patients (i.e. using connectivity between functionally dissimilar medical
the right connection/tubing) is a basic first step. By imple- tubes and catheters to the extent feasible.
menting preventive measures—many of them simple and 2. Specific labeling of device ports is advocated to avoid
inexpensive—wrong route administration errors can be connecting intravenous tubing to catheter cuffs or
effectively eliminated. balloons (3).
3. The use of different, dedicated infusion pumps for spe-
▶ Suggested Actions: cific applications such as epidural infusions has also
The following strategies should be considered by WHO been proposed (12).
Member States.
4. Using only oral/enteral syringes to administer oral/en-
1. Ensure that health-care organizations have systems
teral medications and avoiding the use of adapters and
and procedures in place which:
three-way taps are part of several draft proposals from
▶ Emphasize to non-clinical staff, patients, and fami- the United Kingdom’s National Patient Safety Agency
lies that devices should never be connected or to prevent wrong route errors (13).
disconnected by them. Help should always be re-
5. A combined preventive strategy of performing risk as-
quested from clinical staff.
sessments to identify existing misconnection hazards,
▶ Require the labeling of high-risk catheters (e.g. encouraging manufacturers to design dissimilar cath-
arterial, epidural, intrathecal). Use of catheters eters and tubes to be physically impossible to connect
with injection ports for these applications is to (“incompatibility by design”), acquisition of equip-
be avoided.
ment whose design makes misconnections unlikely,
▶ Require that caregivers trace all lines from their and policy implementation to minimize misconnec-
origin to the connection port to verify attachments tion occurrences has been advocated (14,15).
before making any connections or reconnec-
6. The colour-coding of tubing and connections should
tions, or administering medications, solutions, or
other products. be standardized. The European standardization body
has studied the colour-coding of tubing and connec-
▶ Include a standardized line reconciliation process tors in certain applications and has recommended
as part of handover communications. This should
exploring alternatives to Luer connectors in selected
involve rechecking tubing connections and trac-
applications (16).
ing all patient tubes and catheters to their sources
upon the patient’s arrival in a new setting or service 7. Industry-based standards and engineering design for
and at staff shift changes. medical tubes and catheters that are organ-specific or
▶ Bar the use of standard Luer-connection syringes to need-specific and do not interconnect should be es-
administer oral medications or enteric feedings. tablished and promoted.

▶ Provide for acceptance testing and risk assessment

(failure mode and effects analysis, etc.) to identify
▶ Strength of Evidence:
the potential for misconnections when purchasing ▶ Expert consensus.
new catheters and tubing.
▶ Applicability: 4. Ramsay SJ et al. The dangers of trying to make ends meet: acci-
dental intravenous administration of enteral feed. Anaesthesia and
▶ Wherever patients are treated, including hospitals, men- Intensive Care, 2003, 31:324–327.
tal health facilities, community settings, ambulatory clin- 5. Pope M. A mix-up of tubes. American Journal of Nursing, 2002;
102(4):23.
ics, long-term care facilities, clinics, practices, home-
6. Wrong route errors. Safety First, Massachusetts Coalition for the
care agencies. Prevention of Healthcare Errors, June 1999 (http://www.macoali-
tion.org/documents/SafetyFirst1.pdf, accessed 10 June 2006).
▶ Opportunities for Patient and 7. Tubing misconnections—a persistent and
tially deadly occurrence. Sentinel Event Alert, April
poten-

Family Involvement: 2006. Joint Commission. http://www.jointcommission.

org/SentinelEvents/SentinelEventAlert/sea_36.htm.
▶ Encourage patients and families to ask questions about
8. Vecchione A. JCAHO warns of tubing errors. Health-System Edition,
medications given parenterally or via feeding tubes, to 22 May 2006 (http://mediwire.healingwell.com/main/Default.asp
assure proper medication delivery. x?P=Content&ArticleID=326253, accessed 10 June 2006).
9. Cousins DH, Upton DR. Medication errors: oral paracetamol liq-
▶ Educate patients, families, and caregivers on the proper uid administered intravenously: time for hospitals to issue oral sy-
use of parenteral sites and feeding tubes in the home care ringes to clinical areas? Pharmacy in Practice, 2001, 7:221.
setting and provide instruction on the precautions to take 10. Cousins DH, Upton DR. Medication errors: increased funding can
cut risks. Pharmacy in Practice, 1997, 7:597–598
to prevent wrong route errors.
11. Building a safer NHS for patients: improving medication safety.
London, Department of Health, 2004 (http://www.dh.gov.uk/en/
▶ Potential Barriers: Publicationsandstatistics/ Publications/PublicationsPolicyAndGuid
ance/DH_4071443 accessed 10 June 2006).
▶ Staff acceptance of the concept of wrong route error 12. Koczmara C. Reports of epidural infusion errors. CACCN Dynamics,
prevention. 2004, 15(4):8. http://www.ismp-canada.org/download/CACCN-
Winter04.pdf.
▶ Staff acceptance of never modifying incompatible con- 13. Preventing wrong route errors with oral/enteral medications, feeds
nectors to allow connections. and flushes. National Patient Safety Agency Patient Safety Alert,
Draft responses to 1st consult, January–March 2006. http://www.
▶ Cost of converting to non-connectable delivery systems. saferhealthcare.org.uk/NR/rdonlyres/3F9F3FB2-89B6-4633-
ACE9-A51EC2023EBC/0/NPSAdraftpatientsafetyalertonoralconne
▶ Inability to create an approach or standardization ctorsforstakeholderconsultation.pdf.
of systems. 14. Preventing misconnections of lines and cables. Health Devices,
2006, 35(3):81–95.
▶ Difficulties with a consistent or reliable supply chain for
15. Common connectors pose a threat to safe practice, Texas Board of
some countries. Nursing Bulletin, April 2006.
16. Moore R. Making the right connections. Medical Device
▶ Insufficient generally accepted research, data, and
Technology, 2003, 14(2):26–27.
economic rationale regarding cost-benefit analy-
sis or return on investment (ROI) for implementing
these recommendations.
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▶ Possible treatment delays to obtain compatible equip- addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail:
[email protected] ).
ment if compatible connections are not available.
The designations employed and the presentation of the material in this publica-
tion do not imply the expression of any opinion whatsoever on the part of the

▶ Selected References and World Health Organization concerning the legal status of any country, territory,
city or area or of its authorities, or concerning the delimitation of its frontiers or

Resources: boundaries. Dotted lines on maps represent approximate border lines for which
there may not yet be full agreement.
1. Tunneled intrathecal catheter mistaken as central venous line ac- The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization
cess. ISMP Canada Safety Bulletin, 30 October 2005. http://www. in preference to others of a similar nature that are not mentioned. Errors and
ismp-canada.org/download/ISMPCSB2005-08Intrathecal.pdf. omissions excepted, the names of proprietary products are distinguished by initial
2. Problems persist with life-threatening tubing misconnections. ISMP capital letters.
Medication Safety Alert, 17 June 2004. http://www.ismp.org/ All reasonable precautions have been taken by the World Health Organization
to verify the information contained in this publication. However, the published
newsletters/acutecare/articles/20040617.asp?ptr=y.
material is being distributed without warranty of any kind, either expressed or
3. Wichman K, Hyland S. Medication safety alerts. Inflation ports: implied. The responsibility for the interpretation and use of the material lies with
risk for medication errors. Canadian Journal of Hospital Pharmacy, the reader. In no event shall the World Health Organization be liable for damages
2004, 57(5):299–301. http://www.ismp-canada.org/download/ arising from its use.
cjhp0411.pdf. This publication contains the collective views of the WHO Collaborating Centre
for Patient Safety Solutions and its International Steering Committee
and does not necessarily represent the decisions or the stated policy
of the World Health Organization.