Get Connected

The recognition that IV and non-IV drugs should be administered in separate devices is supported by documentation of wrong-route medication errors in medical journal articles dating back to the late 1960s. The problem of misconnections, particularly enteral and breast milk being injected intravenously into neonates, still happens to this day despite warnings from virtually every affiliated professional and regulatory agency. This article argues that hospitals should do a top-to-bottom assessment of whether their systems can absolutely prevent non- IV fluid tubing from being misconnected to IV lines and take the appropriate measures to correct any deficiencies.

HISTORY

Journal articles dating back to the late 1960s and early 1970s discuss the issue of wrong-route medication errors. In the years since, many articles have been written on medical errors related to tubing misconnections. The Institute for Safe Medication Practices (1), for example, has written about oral to IV misconnections more than a dozen times since its inception in 1994. ISMP and other organisations have long advocated the use of non-luer connectors for administration of any nonparenteral drugs in order to prevent the possibility of an IV infusion of a non-sterile medication. Advocates for a new standard for enteral feeding include the Joint Commission on Hospital Accreditation (Joint Commission), which audits health systems for compliance to best practices, and the National Health Service (NHS) in the UK.