Volume 26, Issue 3 p. 286-293
Invited Review

Tubing Misconnections

Normalization of Deviance

Debora Simmons RN, MSN, CCRN, CCNS

Debora Simmons RN, MSN, CCRN, CCNS

Texas Woman's University, Houston, Texas

National Center for Cognitive Informatics and Decision Making in Healthcare, School of Health Information Sciences, University of Texas Health Science Center at Houston, and The Patient Safety Education Project (PSEP), Buehler Center on Aging, Health & Society, Northwestern University

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Lene Symes RN, PhD

Corresponding Author

Lene Symes RN, PhD

Texas Woman's University, Houston, Texas

Lene Symes, Texas Woman's University, College of Nursing, 6700 Fannin, Houston, TX 77030; e-mail: [email protected].Search for more papers by this author
Peggi Guenter RN, PhD, CNSN

Peggi Guenter RN, PhD, CNSN

Clinical Practice, Advocacy, and Research Affairs, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland

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Krisanne Graves RN, MSN, CPHQ

Krisanne Graves RN, MSN, CPHQ

Texas Woman's University, Houston, Texas

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First published: 16 May 2011
Citations: 39

Abstract

Background: Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible systems. Methods: The purpose of this review of case studies of tubing misconnections and of current expert recommendations for safe tubing connections was to answer the following questions: In tubing connections that have the potential for misconnections between enteral and IV tubing, what are the threats to safety? What are patient outcomes following misconnections between enteral and IV tubing? What are the current recommendations for preventing misconnections between enteral and IV tubing? Following an extensive literature search and guided by 2 models of threats and errors, the authors analyzed case studies and expert opinions to identify technical, organizational, and human errors; patient-related threats; patient outcomes; and recommendations. Results: A total of 116 case studies were found in 34 publications. Each involved misconnections of tubes carrying feedings, intended for enteral routes, to IV lines. Overwhelmingly, the recommendations were for redesign to eliminate universal connectors and prevent misconnections. Other recommendations were made, but the analysis indicates they would not prevent all misconnections. Conclusions: This review of the published case studies and current expert recommendations supports a redesign of connectors to ensure incompatibility between enteral and IV systems. Despite the cumulative evidence, little progress has been made to safeguard patients from tubing misconnections.