Medical Errors

High Reliability is an ongoing quality improvement process used in highly technical industries with high risk. The concept of high reliability involves a safety culture of collective mindfulness in which all employees are acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes. Therefore, everyone in these organizations is always searching for the smallest indication that the environment or a key safety process has changed somehow, which might lead to failure. Once a deficiency is identified, it is eliminated by improving the processes. There are three requirements for achieving high reliability:

• Leadership
• Safety Culture
• Robust Process Improvement

Quality Control (QC) is an ongoing, systematic measurement to determine compliance and accuracy. It is required for some equipment or measurement tests. Examples are checking the high and low control limits on a glucometer or the medication refrigerator's temperature. QC is often a component of or is mentioned with PI.

Human factors engineering uses systems analysis. Humans are considered a critical system component. Human factors analysis focuses on human operators to determine what they are required to do. It combines the scientific methodology familiar to clinicians to explore the causes of error with an engineering approach of task analysis. Human factors analysis goes further than Root Cause Analysis (RCA). This methodology includes:

• Systematic observation of procedures
• Interviews and focus groups
• Activity recording and charting
• Analysis of fatigue and distraction factors
• Analysis of information flow
• Developing and testing models of expected effectiveness

The Reason's(2019) model of human error is based on the premise that adverse outcomes result from a combination of systemic issues such as resource availability, organizational policies and procedures, and human functional errors. Reason's model is called the Swiss cheese model because every layer of defense against errors has holes; the more layers, the smaller the risk of causing harm. There is less chance of the holes lining up to allow an error to occur.

Image 1: Reason's Swiss Cheese Model

   Reason's Model Inputs (Reason, 2019)

• Culture & Leadership
  • Staff shortages
• Technical Support
  • Inexperienced team member
• Training
  • Failed to monitor vital signs
• Clinical Support
  • Poor team

Reason (2019) said that the human condition could not be changed. However, work conditions can be changed. Applying Reason’s model makes it easier to understand that errors reflect problems at the practical and systemic levels. A safe reporting system is used to ensure that system integrity is monitored.

The human cognitive process is how we remember, think, develop, and use motor skills to perform activities individually, in teams, and within organizational systems. Perception equals input: information is perceived through the sensory system. A person cannot take in sensory information with distracted or blurred perception (insufficient light, ambient noise, etc.) and be more prone to misread a label or mishear spoken words.

Long-term memory: information acquired through education and experience is stored in long-term memory. When long-term memory experiences interference (e.g., distraction, multitasking), there is difficulty retrieving and applying previously learned information. Working memory: information from the sensory fields (perception) and long-term memory combine to do the work we label "thinking." Thinking combines sensory input with stored knowledge to call up frequently used patterns and criteria developed through common use to make decisions. When overloaded with physical or emotional demands, there is an increased risk of making incorrect judgments based on confusion or incorrectly applying learned rules.

The impact of design on human factors has four different types of interactions and a wide variety of applications. The science applies an understanding of physical, cultural, and psychological factors to reduce flawed behavior.

Interaction with machines and objects is the most studied area of human factors problems. Most human errors related to human/machine interactions are either the operator's condition or training, bad design of the machine interface, or both. A bad design is one that does not conform to intuitive application. Design flaws can lead to the incorrect use of equipment. Speed, stress, and fatigue increase the likelihood that bad design will lead to error.

Negative impacts on the work environment exist even with the best-designed objects and machines. Human factors problems are encountered stemming from the physical world around us. Physical space, layout, temperature, light, air quality, noise levels, and visual distractions can all interfere with or alter the ability to perform an activity. When these factors become obstacles, they can manifest as inconveniencies or can be harmful. Fatigue from loss of sleep, circadian rhythm changes, and muscular effort expenditure has been identified as one of the major contributors to errors.

As creatures of habit, humans often seek to "workaround" a new system to maintain an old mindset. For example, matching barcodes were encoded on adjoining components to help technicians correctly assemble devices with multiple components. By swiping each piece, a correct assembly was assured. However, reviewers discovered that the procedure was frustrating for some users who, as a workaround, put matching copies of the barcoding on a paper and scanned the paper instead of the equipment pieces, enabling incorrect assembly. Nurses, too, have found that it is easier to scan the patient label from the medication administration sheet rather than taking the medication cart with a scanner to the patient's bedside to scan the patient identification band on the patient's wrist.

When a system problem is solved in isolation and without considering how it might affect the rest of the system, unintended consequences can undo the fix's benefit. An example of this is an automatic forcing function programmed into a hospital medication system to prevent potassium's over-administration. This change inadvertently prevented the administration of high doses when they were needed. A solution can exacerbate existing minor problems or create new opportunities for errors. This change is an unintended consequence. Piloting and field-testing solutions help identify these "downstream consequences."

Human factors problems related to the practice environment tend to be more transient than design problems. Lighting, noise, temperature, even physical space can change from one patient encounter to the next. If the healthcare provider works in multiple practice settings, the opportunity for environmentally-related problems is equally multiplied. Other issues may include things like:

• Equipment models or brands vary
• Equipment storage is too high
• Equipment is not conveniently located
• Equipment is not located in a consistent place
• Environment is not set up to allow effective eye contact and discussion

In various clinical services, care is provided by changing providers over various timeframes and supported by many administrative personnel. Each person acts in their capacity to attend to the patient's needs through their professional and personal lens of a mental model. Inadequate communication can lead to the misalignment of mental models. Interactions among teams and entire systems of healthcare providers are an important area of human factors study. Handoffs, passing on information or responsibility are a particular patient safety problem areas.

Mental models are deeply ingrained assumptions, generalizations, or even pictures/images that influence how we understand the world and how we act. When two people have different mental models of the same situation or process, they are at risk of misinterpreting each other's directions or intentions.

Teams of people working together need to share a common understanding of what needs to be done and how; for example, the same mental model. Teams need efficient communication that is remembered at least long enough for the recipient to take proper action.

Human factors apply wherever humans work. In healthcare, work environments are hazardous. Instruments are potential weapons; drugs are a potential poison, and every worker is a potential killer. The following are human factors problem areas in healthcare:

• Equipment changes and upgrades when training is inadequate
• Hand-off, when there is poor communication
• Infusion pumps when there is poor human interface
• Fatigue
• Labeling when items look alike and sound alike
• Handling Sharps
• Retained foreign bodies in surgery
• Patient bed alarms when there are false alarms and falls
• Physician order entry  when orders are illegible, verbal orders are misunderstood, or there are transcription errors
• Wrong-site surgery

Accept human factors problems as inevitable, although manageable, part of everyday practice. Shift from a punitive to a creative frame of mind that seeks out and identifies the underlying system failures. Efficient, routine identification of human factors needs to be part of every practice and routine investigation of all human factors problems that cause injuries.

Not all design flaws in healthcare environments are obvious hazards. One of the most subtle mistakes is a failure to realize that the best-motivated and most highly trained professionals are potentially lethal agents. Fatigue management in healthcare is a big challenge. Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep over an extended period can lead to several problems, including:

• Lapses in attention and inability to stay focused
• Reduced motivation
• Compromised problem solving
• Confusion
• Irritability
• Memory lapses
• Impaired communication
• Slowed or faulty information processing and judgment
• Diminished reaction time
• Indifference and loss of empathy

Contributing factors to fatigue and risks to patients include:

• Shift length
• Work schedule
• Quantity and quality of sleep

Recommended actions:

Assess the organization for fatigue-related risks. This assessment includes looking at off-shift hours and consecutive shift work and reviewing staffing and other relevant policies to ensure they address extended work shifts and hours. Invite staff to input into designing work schedules to minimize the potential for fatigue.

Since patient hand-off is a time of high risk – especially for tired staff – assess the organization's hand-off processes and procedures to ensure that they adequately protect patients.

Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include: engaging in conversations with others (not just listening and nodding); doing something that involves physical action (even if it is just stretching); strategic caffeine consumption (do not use caffeine when you are already alert and avoid caffeine near bedtime); taking short naps (less than 45 minutes).

Educate staff about sleep hygiene and the effects of fatigue on patient safety. Sleep hygiene includes getting enough sleep and taking naps, practicing good sleep habits (for example, engaging in a relaxing pre-sleep routine, such as yoga or reading), and avoiding food, alcohol, or stimulants (such as caffeine) can impact sleep.

Everyone needs some stress; otherwise, life would be dull and unexciting. Good stress is also known as "eustress." Stress adds flavor, challenge, and opportunity to life. It has also been said that stress is a good motivator, but working when over-stressed, irritated, upset, or shaken will substantially alter one's judgment and can compromise patient safety. Too much stress can seriously affect physical and mental well-being and becomes known as "distress." The angry healthcare provider is aggressive, offensive, and careless, and as a result, is dangerous. Stressful conditions involving personal or business life will cause distractions that can interfere with the provision of safe patient care. They should be recognized and addressed as negative influences on workplace habits.

The clinician should evaluate his or her state of mind before providing patient care, such as medication administration. Providing patient care takes a clear and focused mind, uncluttered by thoughts of aggravation and distress. As mentioned earlier, the healthcare provider with a wandering mind caused by any one of the effects has a decreased awareness of the subtle changes in patient status, a slower reaction time, and an overall lack of concentration. The ability to anticipate complications and to determine appropriate responses is also adversely affected. A major challenge in today's stress-filled world is using stress positively and preventing it from becoming distressed.

The emotionally distressed healthcare provider is more apt to make a medical error than is the rested, clear-headed provider. It should be made clear that tired, disturbed, or cluttered minds decreases critical thinking ability. When disturbed by emotions, the healthcare provider does not concentrate on what they are doing; they concentrate on what has them upset. This distraction could manifest in increased risk-taking behavior such as taking shortcuts, failing to follow policy, and not paying attention to the details. Unsafe behaviors can contribute to an increased risk of medical error.

With severe emotional distress, an individual could turn to substance use or abuse to hide emotional pain. Combined with heavy workloads, this increases the likelihood of error. With the increased risk-taking behavior, aggression could result. The clinician is then labeled as "difficult to work with." Unchecked emotions can lead to aggressive behavior and disciplinary action. The emotionally distressed mind cannot function rationally, or critical thinking is required to provide safe patient care. Managers need to recognize emotionally distressed clinicians.

Standards of practice and hospital policies are instituted and established for patient safety. A policy may not specifically cover special situations, but most clinicians agree that policies and practice standards are needed. The unsupervised and uncontrolled practice would lead to chaos. Some healthcare providers despise the increase in the number of "rules." They stress the negative side of policies rather than the goal of increased patient safety. It must be understood that policies and standards of care can benefit them and be supported and followed.

Healthcare providers should be aware that circumstances and attitude changes could dramatically affect practice habits. Some attitudes that predispose to risk-taking behavior and increase the risk of errors are:

• Enjoying the thrill of crises
• Enjoying impressing coworkers
• Disregarding personal safety
• The illusion of control or overestimating abilities
• Justifying risks because they are taken in a noble cause

Design work to minimize the requirements for particularly fallible human functions such as short-term memory and tasks requiring prolonged attention. For instance, do not rely on memory to retrieve a laboratory test result or when a medication is due. Systemizing these tasks reduce memory-related errors.

Reduce reliance on memory for high-risk procedures or multi-step processes by using checklists. Review the checklists to ensure appropriateness and avoid increasing errors through workarounds that make more errors. While surgical areas generally use preoperative checklists already, it may be wise to use checklists in handoff situations couple brief, useful protocols with procedures developed by the healthcare teams who provide the services. Standardize color match items used together to prevent slips, such as clinicians combining items that should not be used together. Pre-package component items into kits.

As the volume of information increases, there is a need for creative ways to make it more readily available, displaying it where clinicians need it when needed. Making information available at the point of care will make a significant impact on error reduction. Many medication-related claims result from clinicians making decisions about treatment without having all of the appropriate information available. Create forms to promote accurate documentation and electronic ticklers for tracking test results. Block avenues to workarounds that cut out the important transmission of information.

Complexity increases the opportunity for errors. Where possible, critical tasks should be structured so that errors cannot be made. A system's reliability can be improved by perfecting its parts and handoffs, but reducing complexity is even more powerful.

Intimidating and disruptive behaviors foster medical errors. When these behaviors are left unchecked, it can lead to increased turnover, interfere with communication, and interfere with teamwork. Intimidating behaviors can cause a hostile work environment, and numerous errors can occur under these distressful conditions.

Most healthcare providers have experienced or witnessed intimidating or disruptive behaviors. Intimidating and disruptive behaviors include active and passive behavior, such as:

• Verbal outbursts
• Physical threats
• Refusing to perform assigned tasks
• Quietly exhibiting uncooperative attitudes during routine activities

When manifested by healthcare professionals in positions of power, these behaviors include:

• Reluctance or refusal to communicate (i.e., answer questions, return phone calls or pages)
• Condescending language or voice intonation
• Impatience with questions

Disruptive behaviors are often not addressed because the behavior is not reported. Disruptive behaviors may go unreported due to a fear of retaliation, the stigma of whistleblowing, and reluctance to confront an intimidator.

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 35 years of experience in helping healthcare practitioners keep patients safe and lead efforts to improve the medication use process (ISMP, 2018). The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information.

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs, an error's consequences are more devastating to patients. Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm. This error reduction may include strategies like providing mandatory patient education, improving access to information about these drugs, using auxiliary labels and automated alerts; employing automated or independent double checks when necessary; and standardizing the prescribing, storage, dispensing, and administration of these products. A list of high-alert medications is available at ISMP List of High-Alert Medications.

Insulin:

• Establish a check system where one nurse prepares the dose and another nurse reviews it
• Do not store insulin and heparin near each other
• Spell out the word unit instead of using the abbreviation U
• Build-in an independent check system for infusion pump rates and concentration settings

Opiates and Narcotics:

• Limit the opiates and narcotics available in floor stock
• Educate staff about hydromorphone and morphine
• Implement PCA protocols that include double checks of the drug, pump settings, and dosage

Injectable Potassium Chloride (KCL) (or Phosphate):

• Remove concentrated KCL from floor stock
• Move the drug preparation of the units and use commercially available premixed IV solutions
• Standardize and limit drug concentrations

Intravenous Anticoagulants:

• Standardize concentrations and use premixed solutions
• Use only single-dose containers
• Seperate heparin and insulin
• Remove heparin from the top of medication carts

Sodium Chloride Solutions Concentration above 0.9%:

• Remove sodium chloride concentration solutions above 0.9% from nursing units
• Standardize and limit drug concentrations
• Double-check pump rate, drug concentration, and line attachments

The anticoagulants most commonly used and most frequently involved in medication errors are unfractionated heparin, warfarin, and enoxaparin. Contributing factors to medication error with the use of anticoagulants include:

• Inadequate screening of patients for contraindications and drug interactions
• Lack of standardized naming, labeling, and packaging
• Keeping up with the changes to the different dosing regimens, drug interactions, and reversal agents is difficult, particularly for a practitioner who does not routinely prescribe anticoagulants
• Failure to document or communicate individualized instructions and current lab results during handoffs
• Pediatric administration errors because anticoagulants are formulated and packaged for adults

Risk reduction strategies (TJC, 2021e):

• Patient education is vital
• Use approved protocols and evidence-based practice guidelines for:
  • Initiation and maintenance of anticoagulant therapy
  • Reversal of anticoagulation
  • Management of bleeding events related to anticoagulant
  • Perioperative management of all patients on oral anticoagulants
  • Need for baseline and ongoing laboratory tests to monitor and adjust anticoagulant
• Establish a process to identify, respond to, and report adverse drug events
• Use only oral unit-dose products, prefilled syringes, or premixed infusion bags

Patient weight is the basis for calculating a lot of dosing of pediatric medications. Therefore, an accurate weight should be done before administering any weight-based medications, except in emergencies. The kilogram should be the standard for all pediatric weights. Pediatric patients are more prone to medication errors and more likely to be harmed by medication errors.

Most medications used in the care of children are formulated and packaged primarily for adults. Therefore, medications must be prepared in different volumes or concentrations within the health care setting before being administered to children. The need to alter the original medication dosage requires a series of pediatric-specific calculations and tasks, each significantly increasing the possibility of error.

Most healthcare settings are primarily built around the needs of adults. Many settings lack trained staff oriented to pediatric care, pediatric care protocols and safeguards, or up-to-date and easily accessible pediatric reference materials, especially concerning medications. Emergency departments may be particularly risk-prone environments for children.

Children, especially young, small, and sick children, are usually less able to tolerate a medication error physiologically due to still-developing renal, immune, and hepatic functions.

Many children, especially the very young, cannot communicate effectively with providers regarding any adverse effects that medications may be causing.

Pediatric-specific strategies for reducing medication errors:

• Standardize and identify medications effectively, as well as the processes for drug administration.
• Establish and maintain a functional pediatric formulary system with drug evaluation policies, selection, and therapeutic use.
• To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date (e.g., Day 0 or Day 1).
• Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care.
• For pediatric patients who are receiving compounded oral medications and total parenteral nutrition at home, ensure that the doses are equivalent to those prepared in the hospital (i.e., the home dose volume should be the same as the volume of the hospital prepared products).
• Use oral syringes to administer oral medications. The pharmacy should use oral syringes when preparing oral liquid medications. Make oral syringes available on patient care units when "as needed" medications are prepared. Educate staff about the benefits of oral syringes in preventing inadvertent intravenous administration of oral medications.

Ensure full pharmacy oversight and other appropriate staff's involvement—in the verifying, dispensing, and administering of both neonatal and pediatric medications.

• Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication management.
• Provide ready access, including website access, to up-to-date pediatric-specific information for all hospital staff. This information should include pediatric research study data, pediatric growth charts, normal vital sign ranges for children, emergency dosage calculations, and drug reference materials with information about minimum effective doses and maximum dose limits.
• Orient all pharmacy staff to specialized neonatal/pediatric pharmacy services in the organization.
• Provide a dosage calculation sheet for each pediatric critical care patient, including emergency and commonly used medications.
• Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Include reminders and information about monitoring parameters.
• Create pediatric satellite pharmacies or assign pharmacists and technicians with pediatric expertise to areas or services such as neonatal/pediatric critical care units and pediatric oncology units. At a minimum, pediatric medications should be stored and prepared in areas separate from those where adult medications are stored and prepared.

• Use methods to ensure the technology's accuracy that measures and delivers additives for intravenous solutions, such as total parenteral nutrition.
• If dose and dose range checking software programs are available in hospital or pharmacy information systems, they can provide alerts for potentially incorrect doses.
• Medications in automated dispensing cabinets that do not undergo appropriate pharmacist review should be limited to those needed for emergency use or to those medications under the control of a licensed independent prescriber, as specified in Joint Commission standard MM 4.10.
• Recognize that the use of infusion pumps, or smart pumps, is not a guarantee against medication errors. An appropriate education for nurses, pharmacists, and other caregivers regarding these technologies is important for all institutions caring for pediatric patients.
• To prevent adverse outcomes or oversedation, use consistent physiological monitoring, particularly pulse oximetry, while children are under sedation during office-based procedures. Use age and size-appropriate monitoring equipment and follow uniform procedures under the guidance of staff appropriately trained in sedation, monitoring, and resuscitation.
• Providers are encouraged to develop barcoding technology with pediatric capability. Potential errors should be carefully considered while adapting this technology to pediatric processes and systems. For example, a pediatric barcoding solution must provide readable code for small-volume, patient-specific dose labels.

The types of infusion pump errors seen are pumps that do not protect from the free flow of fluids to the patient, the wrong drug concentration, or the wrong rate is set.

Free flow of fluids occurs when the infusate flows freely, under the force of gravity, without being controlled by the infusion pump. Infusion pump tubing needs a built-in, anti-free-flow mechanism. This prevents gravity-free flow by closing off the tubing to prohibit flow when the pump's administration set is removed. If an infusion pump does not have free-flow protection, devices attached to the administration set are available. However, they are not recommended because they are packaged separately and must be manually attached to a set. Clinicians may forget to use the mechanism or may accidentally remove it.

Training and education are important in the prevention of infusion pump administration errors. Be sure to provide in-service to staff who may not be administering medication but may handle the infusion pumps, such as aides, radiology technicians, and transporters. Another concern is that patients, family members, or visitors may mishandle pumps.

Key bump errors can cause errors in the volume or infusion rate. These should be double-checked after entry and before starting the pump. Having a second nurse check calculations and settings for infusion pumps when high-alert drugs are used is recommended.

Medication reconciliation is when healthcare professionals resolve discrepancies when comparing the medications a patient should be using, actually using, and new medications that are ordered (TJC, 2021e). Medication reconciliation is done to avoid medication errors. Handoff situations are prone to errors. Errors can be due to omission, duplication, contraindications, prescription errors, and administration errors. Therefore, the process should be done every time a patient has a handoff or transition in care. A handoff includes a change in setting, service, practitioner, or level of care. Medication reconciliation has five steps:

• develop a list of current medications
• develop a list of medications to be prescribed
• compare the medications on the two lists
• make clinical decisions based on the comparison
• communicate the new list to appropriate caregivers and the patient

When the patient has difficulty with the instructions, someone (family member or caregiver) must be designated and taught about their medications.

Risk reduction strategies include:

• Collect a complete list of current medications for each patient on admission, including dose, frequency, and other key information.
• Validate the home medication list with the patient whenever possible.
• Assign primary responsibility for collecting the home list to someone with sufficient expertise within a context of shared accountability.
• Use the home medication list when writing orders.
• Place the reconciling form in a consistent, highly visible location within the patient chart, easily accessible by clinicians writing orders.
• Assign responsibility for comparing admission orders to the home medication list, identifying discrepancies, and reconciling variances to someone with sufficient expertise.
• Reconcile medications within specified time frames, within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, or upcoming administration times.
• Adopt a standardized form to collect the home medication list and reconcile the variances, including electronic and paper-based forms.
• Develop clear policies and procedures for each step in the reconciliation process.
• Provide access to drug information and pharmacist advice at each step in the reconciliation process.
• Improve access to complete medication lists at admission.
• Provide orientation and ongoing education on procedures for reconciling medications to all health care providers.
• Provide feedback, and ongoing monitoring.

Place the medication list in a highly visible location in the patient's chart and include dosage, drug schedules, immunizations, and allergies or drug intolerances on the list. Create a process for reconciling medications at all care interfaces (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients and responsible physicians, nurses, and pharmacists should be involved in the medication reconciliation process.

On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with them and share it with any care providers, including primary care and specialist physicians, nurses, pharmacists, and other caregivers.

Misconnection of tubing can lead to patient deaths. Causative factors include:

• Luer connectors enable functionally dissimilar tubes or catheters to be connected
• The routine use of tubes or catheters for unintended purposes
• The positioning of functionally dissimilar tubes used in patient care near one another
• Movement of the patient from one setting or service to another
• Staff fatigue associated with working consecutive shifts

Error reduction recommendations include:

• Do not purchase non-intravenous equipment equipped with connectors that can physically mate with a female Luer IV-line connector.
• Conduct acceptance testing for performance, safety, and usability and, as appropriate, risk assessment (e.g., failure mode and effect analysis) on new tubing and catheter purchases to identify the potential for misconnections and take appropriate preventive measures.
• Always trace a tube or catheter from the patient to the origin point before connecting any new device or infusion.
• Recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival to a new setting or service as part of the handoff process. Standardize this "line reconciliation" process.
• Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially important in the care of neonates.
• Inform non-clinical staff, patients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions.
• Certain high-risk catheters (e.g., epidural, intrathecal, arterial) label the catheter and do not use catheters with injection ports.
• Never use a standard Luer syringe for oral medications or enteric feedings.
• Emphasize the risk of tubing misconnections in orientation and training curricula.
• Identify and manage conditions and practices that may contribute to healthcare worker fatigue and take appropriate action.