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Using a Saline Flush “Site Unseen” Could Lead to a Wrong-Route Error
Prior to the event, an anesthesia practitioner had placed an ON-Q C-bloc continuous peripheral nerve-block system (Halyard Health) in the patient’s thoracic paravertebral region to help control pain. The ON-Q system catheter (
When placing the ON-Q system in the patient’s paravertebral region, anesthesia staff decided to attach a short extension set with yellow-striped tubing (
When the technician went to withdraw blood from the patient, the upper part of the patient’s gown obscured the ON-Q C-bloc system affixed to the upper right shoulder; only the CVAD insertion site was visible (
Safe Practice Recommendations
According to the Association for the Advancement of Medical Instrumentation, hospitals will likely start to see newly designed connectors on medical tubing on the market—the end result of a joint working group that is developing standards that will make misconnections virtually impossible because the design of the connectors will no longer be universal as it is now with Luer connectors.1 Instead, the design of each connector will be specific to its application. The first Provisional American National Standards that were released in 2014 are associated with connectors for enteral applications. But there isn’t anything on the horizon that would prevent a Luer connector on a syringe used to withdraw blood from being connected to tubing used for the delivery of regional anesthetics via the ON-Q systems.
Considering all the elements that contributed to this particular event, please take the following precautions to prevent a similar error in your organization.
- Limit access. Limit access to CVAD lines for any purpose, including blood collection, to those with professional health care training and demonstrated competencies; these staff are more likely to know and follow safety measures associated with these devices and are more likely to be knowledgeable about the serious ramifications of misconnections, infections, occlusions, or misadministration of medications. For example, given the risk of occlusion and infection alone, most hospitals do not allow laboratory technicians to draw blood from CVADs. Some hospitals prohibit technician access to these catheters in certain settings, such as critical care units, or for certain patient groups, such as bone marrow transplant patients (as did the hospital where the error occurred).
- Trace access lines. Promote a consistent process for tracing all catheters/lines from the access site into the patient’s body all the way to the end source of an infusion or capped access port before drawing blood, connecting or reconnecting tubing, and/or administering drugs, solutions, flushes, or other products. Remind staff that, for patients with multiple tubes and catheters, situational awareness of each tube’s location and insertion site can be lost, especially if tubing is obscured by clothes and bed sheets. It is also important to fully uncover the insertion site before access is attempted; otherwise mix-ups between look-alike tubing and devices can lead to serious wrong-route errors.
- Communicate practice changes. Changes in dressing locations, types of tubing and connectors, and other altered practices should be readily communicated with all members of the health care team who are providing care to the patient.
- Provide training. Educate all staff who might use or encounter ON-Q C-bloc, ON-Q PainBuster, or other new tubes, catheters, connectors, or drug-delivery systems regarding proper use or access. Include discussions about possible sources of errors and steps to avoid these errors. When possible, include tubing misconnections in simulation training during orientation and annual safety competencies.
- Label lines. Affix labels on lines if the patient has more than one potential connection to a port of entry into the body (e.g., intravenous, arterial, umbilical, enteral, bladder, drainage tubes). For ON-Q C-bloc infusions, affix labels indicating “CONTINUOUS NERVE BLOCK” to alert staff, particularly given that, in many hospitals, only anesthesia staff can manipulate these catheters or dressings.
- Use epidural tubing appropriately. Avoid use of yellow-striped tubing for anything other than its intended purpose: administration of epidural infusions. Its use in other circumstances could result in unintended negative consequences, as it did in this case. When possible, avoid use of any extension sets with the ON-Q C-bloc infusions or tubing connectors that may resemble those used with CVAD catheters and tubing.
- Additional strategies. For addressing the wide-ranging potential for tubing misconnections, hospitals might also want to conduct a self-assessment to identify all products and practices that pose a risk of inadvertent tubing misconnections, with the goal of mitigating identified risks. A tool created in 2012 by Baxter in cooperation with ISMP guides users through a modified risk assessment that evaluates current delivery systems and mating devices, rating ease of connection and potential for patient harm, and assigning a risk priority score.2
The ON-Q C-bloc continuous peripheral nerve-block system (red, green, yellow, and purple arrows) was confused with the central venous catheter (blue and orange arrows), leading to a wrong-route error.
- Association for the Advancement of Medical Instrumentation. Ambitious standards initiative on small-bore connectors moves forward April
242013;Available at: www.aami.org/newsviews/newsdetail.aspx?ItemNumber=1025 Accessed October 4, 2016
- Institute for Safe Medication Practices. Tubing misconnections self assessment for healthcare facilities Available at: www.ismp.org/selfassessments/tubingMisconnections
Accessed October 4, 2016