In late 2005, while visiting a patient in the hospital, a family member noticed a disconnected hose lying on the bed near the patient. Not wanting to bother the nursing staff, the family member connected the tube to a needleless input port on a catheter line. Minutes later, a nurse arrived in the room and noticed blood in the input port tubing. She traced the tubing and saw that the noninvasive blood pressure (NIBP) cuff inflation hose was attached to the port. She immediately disconnected the hose and reattached it to the NIBP cuff, informing the family members not to connect or place any lines or cables on the patient but to instead contact the nursing staff.
The NIBP module was three minutes away from activating an automatic blood pressure determination. If that would have happened, the patient would have been infused with close to 1.5 liters of compressed air in one minute. Instead, the rapid response of the nurse saved the patient's life and gave the hospital a chance to learn from the incident and prevent it from happening again.
The nurse contacted risk management and filled out an unusual occurrence report (UOR) as required by clinical policy. An emergency intensive assessment task force was assembled following this adverse event that included representatives from nursing, biomedical engineering, risk management, pharmacy, and senior medical and clinical executive staff members.
Dave Stiles, director of biomedical engineering at Long Beach Memorial Medical Center in Long Beach, CA, was part of this team. “We determined that the connection system used on the NIBP inflation systems consisted of male and female luer-style slip fittings that can result in the misconnection to a compatible port not intended for the blood pressure hose,” says Stiles. “It was acknowledged at that time that ECRI, AAMI, and the FDA had also reported similar adverse events.”
As a result of the incident and its investigation, the medical center decided to replace all the luer-style connectors on all of its blood pressure devices. “Biomedical contacted several vendors and selected a bayonet-style quick disconnect connection system,” says Stiles. Within seven days of the incident, the biomedical engineering team tested, procured, and installed a new connection system on every blood pressure machine and sphygmomanometer in the medical center.
“We worked with the manufacturer of the disposable cuffs to convert from the slip luer to the bayonet style cuff connector prior to the conversion,” says Stiles. “It turned out that they anticipated this change and were prepared to help us in the conversion. We purchased the hose connector from an independent manufacturer specializing in pneumatic fittings to complete setup.”
On the day of the swap-out, Biomedical worked with Materials and systematically swept the complete medical center, converting the NIBP connection system to the bayonet style, says Stiles. He estimates that they converted close to 1,600 cuffs and hoses during an eight-hour shift.
Such a rapid change presented unique challenges for clinician education. Stiles' team broadcast, via e-mail and fliers, a quick in-service on how to connect and disconnect the tube and cuff. “We provided on-site in-servicing to clinicians not familiar with this connection system,” he says. The medical center also included a video discussion of the incident as an example of its patient safety program during its annual clinical skills lab and safety fair.
Since this incident, Stiles and his team have identified several potential areas of misconnection including sequential pressure devices, respiratory gas and patient safety lines and tubing, and enteral feeding pumps. “We did not see any problems with medical gas systems or fittings, as we were following NCG and NFPA standards in regards to medical gas delivery devices,” he says. He reports that his team's main focus was avoiding attaching non-IV products to IV sets or catheters with female luer slip fittings attached. They also ensured that all disposable respiratory breathing circuits and other circuits did not include removable luer fittings that could be removed and attached elsewhere.
“We have tested our devices for misconnections and have worked with the manufacturers to correct this patient safety issue,” he says. “All of the medical device manufacturers we contacted concerning misconnects cooperated with our medical center in establishing a work-around to avoid medical misconnections.”
“The greatest lesson learned in this experience,” says Stiles, “is that we did not heed the early published warnings of tubing misconnects and were complacent in adopting these changes.”
As a result of this incident, Memorial Medical Center's biomedical department has taken a stronger role on the patient safety committee, informing members of adverse events and product problems that could result in unexpected adverse patient events. Involvement in safety committees is essential to clinical engineers and biomedical equipment technicians becoming “stewards of patient safety,” says Dave Stiles.
Another key to playing this role is to become a member or subscribe to organizations that offer the information needed to stay current with patient safety. “Don't limit yourself just to clinical engineering groups, visit the medical side as well,” says Stiles. “Get invited to the many nursing conferences that involve patient safety.”
Consistently sharing all your findings with the nursing staff can help you communicate to clinicians that you, too, are part of the frontline defense when it comes to ensuring patient safety. “Get into the habit of distributing alerts and equipment issues involving patient safety with the nursing staff, not just by e-mail, but by in-services, safety fairs, and one-on-one encounters,” he says. “You have to get to know your two most important partners in your field: the patients and the clinicians.”
