S. I. Hill2,3, K. R. Dumon2, N. J. Hoke4, G. J. Bordi2,5, L. Owei1, D. T. Dempsey2; 1University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA 2Hospital Of University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA 3University Of San Diego, College Of Arts And Sciences, San Diego, CA, USA 4Hospital Of University Of Pennsylvania, Nursing Department, Perioperative Services, Philadelphia, PA, USA 5Hospital University Of Pennsylvania, Department Of Nursing, Philadelphia, PA, USA
Introduction:
Literature review of Pub Med, Google scholar and The Food and Drug Administration (FDA) suggests that most tubing misconnections lead to adverse events (70%) including death (24%). Abdominal tube misconnections (e.g. enteral feedings hooked to biliary t-tubes) or misidentification (e.g. jejunostomy catheter pulled instead of JP drain) is an important but underappreciated clinical problem. This study aims to examine tube-labeling as a solution to the problem of tubing misconnections.
Methods:
A tube labeling system for abdominal tubes, drains, and stents was developed by the unit based clinical leadership teams from perioperative services and the surgical inpatient units in November 2015 at our university hospital. Printed tube labels with high grade adhesive were placed in each OR, and surgical residents and attendings were educated and asked to place labels at the end of each abdominal operation in which tubes, drains and/or stents were placed. For seven months (January-July 2016) labeling compliance was tracked and surgical unit nurse satisfaction was assessed and postoperative tube misconnections were monitored.
Results:
Labeling compliance gradually increased to 65% after seven months. No tubes were mislabeled. Surgical unit nurse satisfaction was high; all nurses and surgeons interviewed felt this was an important quality improvement initiativeand the most common reason for surgeon noncompliance was “I forgot”. Despite lack of 100% tube labeling compliance, there have been no abdominal tube misconnections so far in 2016 (there were 3 in 2015).
Conclusion:
Routine intraoperative labeling of abdominal tubes, drains, and stents by the operating surgeon or resident may decrease postoperative tube misconnections. Incorporating a reminder into an OR checklist or debrief is likely necessary to achieve 100% surgeon compliance. Even with less than universal compliance, a tube labeling policy increases staff awareness of the important problem of tube misconnections and may help to eliminate this potentially dangerous mistake if tubes are labeled correctly.