With at least 21 hospital patient deaths and nearly 100 other adverse events occurring because plastic tubing intended to deliver food instead went into an IV, a Joint Commission Sentinel Event Alert urges healthcare providers to be extra diligent to avoid such mistakes.
In addition to the 2006 death of a pregnant woman whose feeding tube was placed into her bloodstream in a Kansas hospital, the commission said, this week, "116 other case studies [involved] misconnections directing enteral feeding solutions into IV lines" over the last decade.
What's more, the commission said, "tubing misconnections are underreported," and the adverse events that often result are "sometimes not reported, especially when the mistake does not result in harm to the patient." Or they're reported under another category, such as a medication error.
New tubing connector standards are now in development, to make such misconnections less likely. The first set of standards have already been adopted, the agency said in its alert.
"Small-bore (less than 8.5 mm inner diameter) connectors will be engineered to make it nearly impossible to connect one delivery system to another delivery system that serves a completely different function," the commission said.