Medical Devices
Case Studies Only (Accessible Text)
Case Studies (2009 Medical Safety Calendar)
These case studies are also available in high quality printable PDF format, or in calendar form.
EVENT: Feeding tube erroneously connected to trach tube
POTENTIAL FOR HARM: High
CASE STUDY
- An infant in the pediatric intensive care unit had both a feeding tube and a trach tube
- The feeding tube was inadvertently placed in the trach tube and milk was delivered into the infant’s lungs
- The infant died
THE JOINT COMMISSION SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion
EVENT: Epidural tubing erroneously connected to IV tubing
POTENTIAL FOR HARM: High
CASE STUDY
- An anesthetist and a midwife mistakenly connected an epidural set to the patient’s IV tubing
- The epidural medication was delivered to the IV
- The patient died
THE JOINT COMMISSION SAFETY TIP: For certain high-risk catheters (e.g., epidural, intrathecal, arterial), label the catheter and do not use catheters that have injection ports
EVENT: IV tubing erroneously connected to trach cuff
POTENTIAL FOR HARM: High
CASE STUDY
- A child in a pediatric intensive care unit had both an IV line and a trach tube
- The IV tubing was inadvertently connected to the trach cuff port
- The IV fluid over-expanded the trach cuff to the point of breaking and continuous IV fluids entered the child’s lungs
- The child died
THE JOINT COMMISSION SAFETY TIP: Emphasize the risk of tubing misconnections in orientation and training curricula
EVENT: IV tubing erroneously connected to nebulizer
POTENTIAL FOR HARM: High
CASE STUDY
- During a nebulizer treatment, the patient’s oxygen tubing fell off the nebulizer and the patient’s IV tubing was inadvertently attached to the nebulizer
- When the patient inhaled, a moderate amount of IV fluids was aspirated into the patient’s lungs
- The misconnection was identified by the respiratory therapist and the patient survived
THE JOINT COMMISSION SAFETY TIP: Do not purchase nonintravenous equipment that is equipped with connectors that can physically mate with a female luer IV line connector
EVENT: Oxygen tubing erroneously connected to a needleless IV port
POTENTIAL FOR HARM: High
CASE STUDY
- A patient’s oxygen tubing became disconnected from his nebulizer and was accidentally reattached to his IV tubing Y-site by a staff member who was completing a double shift
- The patient died from an air embolism, even though the connection was broken within seconds
THE JOINT COMMISSION SAFETY TIP: Identify and manage conditions and practices that may contribute to healthcare worker fatigue, and take appropriate action
EVENT: Blood pressure tubing erroneously connected to IV catheter
POTENTIAL FOR HARM: High
CASE STUDY
- An ER patient had an IV heparin lock but no IV fluids had been started. The patient also had a noninvasive automatic BP cuff placed for continuous monitoring
- The BP cuff tubing was disconnected when the patient went to the bathroom
- When she returned, her spouse mistakenly connected the BP cuff tubing to the IV catheter and approximately 15 mL of air was delivered to the IV catheter
- The patient died from a fatal air embolus, despite resuscitation efforts
THE JOINT COMMISSION SAFETY TIP: Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions
EVENT: IV tubing erroneously connected to nasal cannula
POTENTIAL FOR HARM: High
CASE STUDY
- A nurse’s aide inadvertently connected a patient’s IV tubing to the nasal oxygen cannula upon transfer to the step down unit
- The misconnection was not noted until 4 hours later, when the patient complained of chest tightness and difficulty breathing
- The patient was treated for congestive heart failure and survived
THE JOINT COMMISSION SAFETY TIP: Recheck connections and trace all patient tubes and catheters to their sources upon the patient’s arrival in a new setting or service as part of the handoff process. Standardize this “line reconciliation” process.
EVENT: IV tubing erroneously connected to enteral feeding tube
POTENTIAL FOR HARM: Moderate
CASE STUDY
- A child had both a gastric feeding tube for nutrition and an IV for medication and hydration
- When the child’s gown was changed, a family member inadvertently attached the IV tubing to the gastric feeding tube
- The medication was delivered through the feeding tube into the stomach
- There was no patient harm since the event was noted in a timely manner
THE JOINT COMMISSION SAFETY TIP: Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions
EVENT: Syringe erroneously connected to trach cuff
POTENTIAL FOR HARM: High
CASE STUDY
- The patient had both a central line with 3 ports and a trach tube
- Medication intended for the central line was inadvertently injected into the trach cuff
- The trach cuff was damaged and the medication entered the patient’s lungs
- A new trach tube was inserted and the patient survived
THE JOINT COMMISSION SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion
EVENT: Foley catheter erroneously connected to NG tube
POTENTIAL FOR HARM: Low
CASE STUDY
- A patient was found with her Foley catheter disconnected from its drainage bag. One end of the catheter was still in her bladder and the other end was connected to her nasogastric (NG) tube
- Urine was noted to be flowing into her NG tube
- The NG tube was connected to suction and more than 300 mL of urine drained
- The patient’s vital signs were stable and her laboratory results were within normal limits
THE JOINT COMMISSION SAFETY TIP: Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions
EVENT: Enteral feeding tube erroneously connected to ventilator in-line suction catheter
POTENTIAL FOR HARM: High
CASE STUDY
- A patient’s feeding tube was inadvertently connected to the instillation port on the ventilator in-line suction catheter
- Tube feeding was delivered into the patient’s lungs
- The patient died
THE JOINT COMMISSION SAFETY TIP: Emphasize the risk of tubing misconnections in orientation and training curricula
EVENT: Pulsatile anti-embolism stocking erroneously connected to IV heparin lock
POTENTIAL FOR HARM: High
CASE STUDY
- A patient admitted for stroke had a pulsatile anti-embolism stocking (PAS) on the left lower extremity and an IV heparin lock in the right ankle
- The patient was alert and oriented on admission but shortly after was found unresponsive and cyanotic
- The PAS pump tubing was found connected to the IV heparin lock in the patient’s right ankle
- The patient died of a massive air embolus
THE JOINT COMMISSION SAFETY TIP: Manufacturers should implement “designed incompatibility” as appropriate, to prevent dangerous misconnections of tubes and catheters