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Medical Device Misconnection: the Wrong Tube Can Kill

By lladmin on July 29, 2019

Our last blog article dealt with medication administration errors—when medication is delivered to patients through the wrong route. (For example, something that was meant to be taken orally is infused into an IV drip.) Now, we’ll be homing in on how doctors and nurses make these mistakes: with medical device misconnections.

People who are hospitalized often have multiple tubes and catheters running into their bodies, and the connectors on these devices, with a little wrangling, can fit nearly any syringe. Most have Luer locks, a screw connection that creates a leak-free seal. It’s a standardized fitting used by all medical supply companies, which allows hospitals to connect needles, tubing, and other equipment interchangeably. But this port compatibility also makes it possible for the wrong line to be connected very easily. And it often is.

That is why Leventhal Puga Braley P.C. takes such a hard line on this type of medical malpractice. If you suspect an error was made in giving you or a family member medication, please call (877) 433-3906 to speak with a Denver medical malpractice lawyer. We handle cases across the county and the consultation is free.

Newborns Are at Increased Risk for Wrong-Route Errors

It’s a sad fact that children in neonatal intensive care units are more likely to experience wrong-route errors: the medical situations are complex, powerful drugs are used, and the patients are extremely vulnerable. The Luer lock is a huge component in these errors, since nutrients and medications are often infused with similar syringe pumps. According to Neonatal Perspectives, the incidence of medication errors in the NICU is reported to be as high as 57%–which is eight times greater than the general hospital population.

Between 1997 and 2007, medical malpractice claims involving the erroneous administration of drugs had the highest average payout of all medication-related lawsuits: $214,240 per claim. The Institute for Safe Medication Practices called out the common practice of nurses using IV syringes to measure out oral solutions as the main culprit. When a non-oral syringe is used for this purpose—say, one with a Luer lock—the nurse can connect it to the patient’s IV line after a momentary distraction or a change of hands. Oh yes; it happens all the time. More than once, a feeding has been given to a newborn baby intravenously. It is nearly always fatal.

What Should Hospitals Be Doing?

Wrong-route errors are a complex problem with no one “fix.” Hospitals need to:

  • Have standardized labeling practices for drugs, including barcode scanning to ensure the right drug is being used for the right patient. (Tall-man lettering has been found to cut down on errors by emphasizing disparities in similar drug names—DOPamine vs. DOBUTamine.)
  • Label all access lines to the patient—nasogastric, enteral, parenteral tubing and catheters—clearly.
  • Do not use lookalike multi-purpose tubing. Have designated tubes for different functions that do not fit devices used for other functions.
  • Recheck the manufacturer label warning before administering a drug (make sure the pharmacy label doesn’t cover it).
  • Recheck connections and trace all tubes and catheters on the patient to their sources before delivering the drug (also called “line reconciliation”). This is especially important upon a new patient’s arrival and as part of the handoff/patient transfer process.
  • DO NOT use IV syringes to measure dosages of solutions meant to be given orally. Use oral syringes, which cannot be connected to IV ports.
  • Have proper storage and disposal of drugs (for example, separate similar-looking bottles and medications with similar names).
  • Have standardized checklists for inpatient procedures with little room for interpretation of policies.
  • Have adequate staff to cover all patients, so nurses are not overtaxed and there is an extra layer of protection in the form of “more eyes.”
  • Train staff on common administration route errors, and have refresher training for transfers and new staff. Make it important that these mistakes not be made.
  • WARN patient and their families to never try to reconnect a seemly unlinked line or tube. Instruct them to call for help from clinical staff to connect or disconnect devices.

Manufacturers also bear responsibility for this epidemic. Similar drug naming, labeling, packaging, and device design make it possible for these errors to be made. The design is a sticking point for the Institute for Safe Medication Practices, and we have to agree with them. Manufacturers need to “force function” by making products that physically cannot be connected interchangeably.

However, the devices aren’t the bottom line. A joint US-England survey of two studies looked at error rates associated with smart infusion devices and concluded, “introducing more sophisticated technology without reviewing the policies and practices that surround those technologies does not necessarily improve patient safety.”

Always, the responsibility comes back to people. A dedication to safety and willingness to question what’s being done—that is, a medical facility’s willingness to take ownership of patient safety and empower employees to speak up—is the best weapon against wrong-route errors.

The Right Route Is Only a Piece of the Puzzle

Remember, determining the right route for medication delivery is only a small part of a medical professional’s duty of care.

Leventhal Puga Braley P.C. handled a painful case involving a young girl who was born with a common congenital heart defect – easily repaired with surgery. At four days old, she was transferred to Children’s Hospital Colorado in Aurora, where doctors put her on a medication called prostaglandin in preparation for the procedure. But a nurse gave her the wrong dose of prostaglandin and her heart stopped on the operating table. Doctors could not resuscitate her for 33 minutes, which caused the newborn to suffer a severe hypoxic-ischemic brain injury. As a result, she developed cerebral palsy with significant intellectual disability and cognitive impairment. Throughout her life, she will require round-the-clock care and supervision. We took this case to trial and received a $17.8 million verdict for her family; the largest medical malpractice verdict in Colorado to date.

Justice can be done, but it requires experience to successfully pursue in court. Leventhal Puga Braley P.C. has those qualities in abundance, as well as the depth of medical knowledge and financial resources needed take on the toughest opponent—or the largest hospital. Call (877) 433-3906 for a no-cost initial consultation if you suspect malpractice.

Additional Information:

U.S. Food & Drug Administration: Examples of Medical Device Misconnections

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Posted in: Medical Malpractice