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Related Experiment Video

Updated: Jul 21, 2025

High Throughput Microfluidic Rapid and Low Cost Prototyping Packaging Methods

High Throughput Microfluidic Rapid and Low Cost Prototyping Packaging Methods

Published on: December 23, 2013

Reducing Tubing and Device Misconnections.

Dana Mazzella¹

¹Dana Mazzella is a clinical nurse IV at Memorial Sloan Kettering Cancer Center in New York City. Contact author: mazzelld@mskcc.org. The author has disclosed no potential conflicts of interest, financial or otherwise.

The American Journal of Nursing

|July 27, 2023

Summary

Implementing new protocols significantly reduced tubing and device misconnections, enhancing patient safety. Staff education and line reconciliation practices were key to preventing these harmful medical errors.

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Area of Science:

Healthcare Quality Improvement
Patient Safety Research
Nursing Practice Innovation

Background:

Tubing and device misconnections pose a significant risk of patient harm and mortality.
Internal quality data revealed 11 reported misconnections, highlighting the need for improved prevention strategies.
Existing literature suggests environmental safety, clinician education, and real-time error reporting as key interventions.

Approach:

A quality improvement project was initiated to explore and implement evidence-based prevention strategies.
A literature review identified recommended practices, including line tracing and reconciliation.
Nursing policies were revised, and comprehensive education was provided to clinical staff on best practices.

Key Points:

Post-implementation data showed a reduction in misconnection incidents to two within four months.
Clinical staff demonstrated adoption of new terminology and practices, such as line tracing and reconciliation.
Education and policy changes empowered staff to identify and mitigate risks associated with misconnections.

Conclusions:

The implemented prevention strategies, particularly education and policy revisions, were effective in reducing tubing and device misconnections.
Integration of line tracing and reconciliation into routine practice improved patient outcomes and safety.
This quality improvement project underscores the importance of evidence-based practices in enhancing patient safety indicators.