This Signal concerns the risk of harm relating to the use of intravenous connectors in children and neonates.
A sample incident reads:
“Scalp Vein placed in child with single lumen bionector T - Piece. T - Piece dislodged from cannula as not Luer lock connection. Child already acutely unwell. Significant blood loss. Resulted in child being transferred to PICU.”
Intravenous connectors are integral to the administration of intravenous fluids and drugs via a patient’s cannula. They are often referred to as T pieces or luer connectors. Luer lock connectors screw into a cannula whereas luer slip are pushed in.
The National Reporting and Learning System (NRLS) database was searched for incidents reported from 1 November 2003 to 22 October 2010. The search identified 26 relevant incidents. Of these 22 were reported as resulting in low or no harm. Three resulted in moderate harm and one was reported as resulting in severe harm.
In 16 reports the T piece had become disconnected from the cannula resulting in the loss of blood, intravenous fluids, drugs or Total Parenteral Nutrition (TPN). Seven incidents identified that a luer slip connector had been used which had resulted in disconnection. In three incidents a luer slip connector had been used inappropriately to connect to an arterial line. Three incidents highlighted that a luer lock connector had been used, but not screwed into the cannula correctly, resulting in disconnection.
There is evidence of patient harm resulting from blood loss, intravenous fluid loss or the loss of drugs or TPN, as a result of the disconnection of intravenous connectors, particularly luer slip devices.
Staff should also be made aware of the similarity in packaging for both luer lock and luer slip connectors. If both are to be kept in the clinical area a risk assessment should be undertaken to consider the use of each type.
Please contact us with information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.