Wrong connection of enteral feeds to the central venous line

Wrong connection of enteral feeds to the central venous line


Background:

The patient who is a 19 year old engineering student, was admitted with a Traumatic brain injury due RTA. The patient received neurological care that included intubation, tracheotomy, decompressive craniectomy and daily care. He had not regained conscious despite all this measures. He was transferred to neuro SDU for continued care. He was stable during night rounds and had no new issues.

Later he received daily morning nursing care, which included eye, mouth, skin, tube, central line, bladder and bowel care. The patient developed out of blue cardio repository arrest and despite code blue call and CPR efforts for 35 minutes he could not be resuscitated and was declared dead.

During the post arrest debriefing the medicine senior resident who was the Code Blue Team leader discovered that enteral feed was connected to one of the inlets of the triple lumen central line and was flowing in through an enteral pump set at 100mL per hour.  The wrong connection seemed to have happened during morning care.

In your opinion

• What is the main cause of the event?

• What are the additional factors that might have contributed to the event?

• What should be done to prevent recurrence and occurrence? 

If you have anything to add please feel free to share your views in the comments section below!


About Author
Though i am an anesthesiologist and intensivist by training I consult for health care quality and safety management now
About PlexusMD MedicoLegal Desk
PlexusMD Medicolegal Desk brings out key facts and learnings from cases involving Doctors and Hospitals across the country to update Doctors with the latest regulations, avoid common mistakes and stay safe while discharging their duties.
Dr. S●●●●●●●●●●n K●●●●●●i and 26 others like this12 shares
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Dr. R●●●●●●r N●●●r
Dr. R●●●●●●r N●●●r General Surgery
Strict supervision and clear instructions to The attending staff and clear marking on the individual fluid should be given to avert such mishaps .
Feb 25, 2019Like
Dr. U●●y S●●h
Dr. U●●y S●●h Pathology
Yes
Feb 25, 2019Like
Dr. G●●●n G●●l
Dr. G●●●n G●●l General Surgery
Cerebral hypoxia
Mar 14, 2019Like