By Julia Marders, RN, MS
(Originally Published September 2003)
After going to the bathroom, a confused patient mistakenly attached the air hose from a sequential compression device (used with antiembolism stockings) to his I.V.. tubing. Luckily, the compressor was turned off so air didn't enter the LTV. tubing. If it had, he could have sustained an air embolism and died.
What went wrong?
Some medical devices intended for different uses have compatible luerconnector designs, so the potential for unintentional cross-connection exists. You can minimize the risk of accidental, potentially fatalcross-connections with a few simple precautions:
- Be familiar with any medical device you're using. Follow the manufacturer's recommendations and cautions regarding compatibility with other devices.
- Be aware of the potential for inadvertent cross-connections.
- Notify your facility's risk manager and biomedical department of any potentially dangerous compatibility issues involving medical devices in your patient-care area.
- If your patient is confused, check on him frequently. Hide tubings as much as possible so he won't be tempted to unplug and reconnect them. Remind him to call for assistance if he needs to get out of bed.
- If a patient sustains a serious injury or dies, or if equipment malfunctions because of a known or suspected device cross-connection, notify the person at your facility who's responsible for reporting such problems.
Julia Marders is a nurse-consultant for the Center for Devices and Radiological Health of the Food and Drug Administration in Rockville, MD. Although you need to support the adverse event-reporting policy of your health care facility, you may voluntarily report a medical device that doesn't perform as intended by calling MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178; online at http://www.fda.gov/medwatch). The opinions and statements in this report are those of the author and may not reflect the views of the Department of Health and Human Services. Beverly Albrecht Gallauresi, RN, BS, MPH, coordinates Device Safety.