Module 10 IV Tubing and Tubing Labeling Trace

Module 10 IV Tubing and Tubing Labeling: Trace the Lines!! Karen Bottom RN, MSN, CNM, WHNP Cindy Anderson RN, MSN, CNS, CCRN Safety Summit 2014

Why Trace the Lines. . . • Pitocin Story. . – A nurse hung an infusion of pitocin as well as a primary IV on a post-partum patient. But she mistakenly programmed the pitocin infusion pump for the rate of the primary IV and the primary IV for the rate of the pitocin causing the patient to recieve an excessive infusion of the pitocin. – Had she “traced” her lines. . . which includes a review of the pump settings. . . all the way from the bag to the patient this error might have been caught before the infusion was started. 2

Why Trace the Lines…. • Insulin Story… – A nurse in the ED received an order for an insulin infusion. The nurse programs the pumps and then places the insulin infusion into one pumpp the primary infusion on the second pump. . A second nurse “double-checked” the insulin label for correctness and saw a pump correctly programmed. – However, the lines were reversed and the insulin infusion was placed on the pump programmed for the primary infusion. The “double-check” did not include tracing the lines as it should have. – If both nurses had not only performed the “double-check” but also independently traced the lines, the error in line placement in the pumps might have been caught before the infusion was begun. 3

Preventing Medication Errors from Tubing Misconnections • Clinical Services Policy 8720. 0192 reminds staff to: • Label each pump with the solution infusing. This can be done in most cases by using the pre-programmed drug library. • When two or more lines are in use, you are to label each line nearest the point of connection to the patient with the name of solution infusing. • Finally, trace each line from the solution to the pump (checking the pump settings to ensure the pump is programmed correctly) and then to the point of connection to the patient to verify it is correctly connected to the patient’s IV site. 4

Hello Humankindness Three things in human life are important. The first is to be kind. The second is to be kind. And the third is to be kind. Henry James What could be more kind to our patients than to ensure our IV infusions are safely being administered by taking the time to “Trace the Lines”… 5