When I was starting out in nursing, I used to divide my assignment list on my orthopedics unit by those patients who had IVs and those who did not. The patients with IVs were the exception, not the rule and they required more of your attention. Ever counted an IV drip rate using the second hand on a wrist watch? Back then, IVs were something special, not something that every patient had. Through the years, technology has made tasks (like counting the drip rate for example) easier but I wonder if it has also made us a bit complacent. IVs may be more common now but there is still room for innovation and improvement.
Today, most patients have an IV and the critically ill have several other lines and tubes (like feeding and oxygen) connecting to various machines. In our critical care units, the number of tubes and lines increases. For our smallest patients, the premature infants in our neonatal units, they’re virtually lost in a sea of spaghetti! If you do a Google image search of “icu patients” you’ll see a host of photos that illustrate the challenge that is facing nurses today. Misconnect the wrong line and you could do serious harm to the patient; even death.
Knowing how to manage these tubes and lines, and the machines and medicine bags they’re connected to, has become a big part of nursing care. But here’s the real issue. Many of these lines look similar and have interchangeable connectors. It is far too easy to connect the wrong tubing to the wrong machine or to inject nutritional products into a line meant only for medications. It’s not like the IV tube has a square connection and the oxygen tube a round one. They’re all the same. This issue caught the eye of The Joint Commission and in 2006, they issued a sentinel event alert on tubing misconnects.
So in order to address this a few years ago, we brought together a group of about 50 clinicians to look at ways to prevent these tubing and line errors and improve patient safety. We developed a six-step checklist, similar to the types of pre-flight checklists pilots use, called I-TRACE [pdf] (Illuminate, Touch, Review, Act, Clarify, Expect) to guide caregivers every time they interact with one of these lines. We actually just received the Cheers Award [pdf] from The Institute for Safe Medication Practices (ISMP) for our work on I-TRACE so I am really proud of our team. In addition to I-TRACE we also promoted the use of oral syringes to help reduce the potential for misconnects. Oral syringes have blunted tips that cannot be used with IV tubing so they’re easier to distinguish among IV syringes. After we began promoting this, we saw an increase in the use of oral syringes which told us we were on the right track.
Still, we wanted to do better. Our checklist was good but our team wanted to focus on the root cause; the tube connections. That brings us to today. We are beginning to meet with the manufacturers who make the machines that the tubes connect to so we can start modifying these connections. What if you could redesign the point of entry to ensure that the only possible connection is the right one? Can you imagine the impact that would have on improving patient safety? This is bigger than HCA. These types of changes would help any hospital who works with these manufacturers serve their patients better.
I know it’s a small step, but it’s the right one to take.