In a previous program, we cited a case where the tubing from a portable blood pressure monitoring device was mistakenly connected to the patient's IV line, and the patient died from an air embolism. In another case, an air supply hose from a pneumatic compression device was inadvertently hooked up to a needleless IV tubing port. This patient, too, could have died, if the mistake hadn't been caught in time.

In a recent Safety Alert, the Institute for Safe Medication Practices reported on another case of tubing misconnection, this time involving a hospitalized child being treated for asthma. The tubing that connected an oxygen wall outlet to the child's nebulizer became disconnected. A staff member later reattached this oxygen tubing to the Baxter Clearlink valve on the patient's IV set, and the child died. Baxter has issued a safety alert to directors of nursing on this type of tubing misconnection hazard.

ISMP notes that oxygen tubing generally doesn’t have a Luer connector, but they point out that it’s still possible to make a connection between the tube and a Clearlink valve if you use excessive force. Although this kind of connection might not hold for very long, it only takes seconds for an air embolism to occur and kill the patient if you connect an oxygen or air tube to an IV port.

ISMP says that staff training is vital in preventing these kinds of accidents. They suggest that whenever tubing is connected or reconnected to a patient, staff should be required to completely trace it from the patient to the point of origin. They also note that if IV lines were labeled, this could help alert staff if they were about to access that line accidentally.

ISMP points out that it's possible for anyone, even a trained professional, to misconnect patient lines, but that untrained people, like ancillary staff, students and transport personnel, are more likely to commit errors. And so ISMP recommends that these people not be allowed to connect and disconnect patient tubing.

ISMP notes that in the rush of patient care, sometimes a student or a transport worker or a lab technician will be asked to connect or disconnect a tube. ISMP suggests that these people be taught how to refuse if someone asks them to connect or disconnect medical tubing.