Debora Simmons

Enteral Feeding Misconnections: A Consortium Position Statement

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.

Tubing Misconnections Normalization of Deviance

BACKGROUND Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible systems. METHODS The purpose of this review of case studies of tubing misconnections and of current expert recommendations for safe tubing connections was to answer the following questions: In tubing connections that have the potential for misconnections between enteral and IV tubing, what are the threats to safety? What are patient outcomes following misconnections between enteral and IV tubing? What are the current recommendations for preventing misconnections between enteral and IV tubing? Following an extensive literature search and guided by 2 models of threats and errors, the authors analyzed case studies and expert opinions to identify technical, organizational, and human errors; patient-related threats; patient outcomes; and recommendations. RESULTS A total of 116 case studies were found in 34 publications. Each involved misconnections of tubes carrying feedings, intended for enteral routes, to IV lines. Overwhelmingly, the recommendations were for redesign to eliminate universal connectors and prevent misconnections. Other recommendations were made, but the analysis indicates they would not prevent all misconnections. CONCLUSIONS This review of the published case studies and current expert recommendations supports a redesign of connectors to ensure incompatibility between enteral and IV systems. Despite the cumulative evidence, little progress has been made to safeguard patients from tubing misconnections.

Error-Avoidance Recommendations for Tubing Misconnections When Using Luer-Tip Connectors: A Statement by the USP Safe Medication Use Expert Committee

Recommendations are provided to assist health care professionals, manufacturers, and consumers in the appropriate handling of tubing with Luer-tip connectors.

Differentiating close calls from errors: A multidisciplinary perspective

Objectives: To investigate the ability of health care providers to correctly identify close calls and errors and to examine the role of close call and error definitions on such identification. Methods: Sixty-eight health care providers from a large, academic medical center institution participated (22 physicians, 23 nurses, 13 pharmacists, and 10 physician assistants). Five hypothetical errors and 5 close call scenarios were developed based upon actual errors and close calls from the institution. Each participant was provided with all 10 scenarios to evaluate. Additionally, to determine the importance of including a definition of a close call or error, participants were randomly assigned to 1 of 2 groups: group 1 received definitions of errors and close calls before reading each scenario, whereas group 2 did not receive these definitions. After reading each scenario, providers classified the scenarios as errors, close calls, or neither. Results: The majority of participants correctly identified close call and error scenarios. The percentage of scenarios categorized correctly by profession for close calls and errors, respectively, was: 67.8% and 74.8% for nurses, 73.8% and 78.5% for pharmacists, 74% and 80% for physician assistants, and 67.6% and 78.2% for physicians. Participants with definitions of close calls were significantly more likely to identify them correctly than participants without definitions (t(65) = 2.303, P < 0.05). The same finding was not replicated for error scenarios (t(66) = 0.149, P > 0.05). Conclusions: The rate of incorrectly identifying close calls, although relatively low, suggests that close call reporting systems might be underutilized due to provider knowledge about these medical situations. The findings provide support for the need to educate providers about close calls to maximize the likelihood of receiving close call reports.

Cause-and-effect Mapping of Critical Events

Health care errors are routinely reported in the scientific and public press and have become a major concern for most Americans. In learning to identify and analyze errors health care can develop some of the skills of a learning organization, including the concept of systems thinking. Modern experts in improving quality have been working in other high-risk industries since the 1920s making structured organizational changes through various frameworks for quality methods including continuous quality improvement and total quality management. When using these tools, it is important to understand systems thinking and the concept of processes within organization. Within these frameworks of improvement, several tools can be used in the analysis of errors. This article introduces a robust tool with a broad analytical view consistent with systems thinking, called CauseMapping (ThinkReliability, Houston, TX, USA), which can be used to systematically analyze the process and the problem at the same time.