Medical Errors Involving Tubes Drawing Scrutiny
Hospitals, government agencies and safety organizations "are scrambling for solutions" to prevent hospital staff from inadvertently connecting tubes and catheters to the wrong device or medication, the Wall Street Journal reports.
According to the Journal, "a small but steady number" of hospital errors each year involve misconnections, including "intravenous lines connected to epidural lines, bladder irrigation solutions connected to central IV catheters ... and intravenous solutions sent through urinary tract, epidural and kidney dialysis catheters."
The not-for-profit hospital accreditation body the Joint Commission says misconnections generally are unreported and there is no accurate way to compare errors on a year-to-year basis, but they are a "persistent and potentially deadly occurrence."
According to the not-for-profit U.S. Pharmacopeia, more than 300 misconnections occurred between 1999 and 2004, and it is likely that more than 1,000 have occurred since 2004.
Experts say that the main cause of misconnections is the universal connection system known as Luer fittings, which connect a broad range of devices.
Several hospital alliances and device manufacturers are working to address the problem.
Premier, the purchasing alliance of 1,500 U.S. hospitals, is leading the "most significant initiative" by educating hospital staff about the errors and working with medical device manufacturers to redesign equipment so tube connectors are not compatible with each other, the Journal reports.
A system designed by Viasys Healthcare that uses new connectors that are incompatible with Luer connectors and other tubes has received FDA approval.
Other groups are working to develop technical standards that could be used in designing safer tubing and connection systems.
In addition, FDA, which says the Luer system is a significant public health issue, asked the Beaumont Technology Usability Center to create educational tools to help hospitals remedy misconnection issues and increase awareness of the problem among staff (Landro, Wall Street Journal, 6/27).