A patient receiving critical care often has many types of tubing and connections between tubing. A number of factors may increase the risk of a tubing misconnection.
Risk factors for tubing misconnections:
(1) transfer of the patient
(2) emergency situation, including rapid deterioration in the patient's condition
(3) provider inexperience
(4) high provider turnover
(5) large number of tubes in close proximity ("spaghetti")
(6) line connections that are loose or insecure
(7) line connections that unlabelled and/or that look alike
(8) use of line connectors that allow incorrect connections to be made (nonspecific)
(9) nonstandard use of equipment (lines, connectors, syringes), especially if undocumented or left in place beyond an immediate need (deviation from protocol)
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Specialty: Critical Care, Emergency Medicine