Epidural and Intravenous Infusion Mix-Ups
MedSun: Newsletter #17, September 2007

From ISMP Medication Safety Alert!® Nurse Advise-ERR
July 2007, Volume 5, Issue 7
©2007 Institute for Safe Medication Practices (ISMP)

A nurse accidentally infused potassium chloride injection by the epidural route into a postoperative patient with hypokalemia. The nurse intended to connect the IV tubing from the potassium minibag (20 mEq in 50 mL) to the maintenance IV infusion line via a Y-site port. Instead, she connected the potassium bag to a Y-site port located on the patient’s epidural line through which fentanyl and bupivacaine was infusing. The patient received the entire contents of the minibag over 2 hours, after which the nurse disconnected the minibag. Shortly thereafter, an anesthesiologist discontinued the epidural line. Later, the nurse returned to the patient’s room to hang another dose of potassium chloride and realized that she must have connected the prior infusion to the epidural tubing. The anesthesiologist and surgeon were immediately notified. Fortunately, the patient developed no symptoms during or after the potassium infusion.

At first glance, the underlying cause of this error may seem clear—using tubing with a Y-site access port for an epidural infusion. However, examining why this error occurred in a facility that typically used special epidural tubing without access ports led to the discovery of additional causal factors.

Standard procedures not followed:
For patients with epidural infusions in place for analgesia during the immediate postoperative period, post-anesthesia care unit (PACU) staff typically attached special epidural tubing without an access port. Standard procedures were not followed in this case. The patient’s surgery occurred on a weekend, and the patient had been recovered in ICU, not PACU. While in ICU, the epidural catheter was capped because it started leaking. Thus, the patient was transferred to a medical-surgical unit with a capped epidural.

Faulty procedure and tubing:
Usually, when staff nurses receive a patient in the medical-surgical unit with an epidural infusion, the special tubing has already been attached. In fact, before this error, a patient had never come to the unit with a capped epidural catheter. When the patient complained of pain, the nurses decided to start the epidural analgesic per the standing orders that had remained on the chart. In preparation, they read a recently written policy and procedure for epidural analgesia which, unfortunately, did not mention the need for special tubing without access ports. In fact, epidural tubing was not available in the unit’s supplies. Thus, regular IV tubing had been used to connect the epidural analgesia, allowing the potassium infusion to be accidentally connected to the epidural infusion port.

Double-checking policy not known:
The hospital had a rigorous policy regarding independent double-checks for IV potassium infusions in concentrations greater than 60 mEq/L. If the policy had been followed, the doublecheck would have required the nurse to show a colleague at the bedside exactly where she had attached the IV potassium infusion. However, the double-check policy had just been implemented a few weeks prior to the error, and some nurses were unfamiliar with its scope. Most of the nurses thought the policy required two staff to double-check the medication label and dose against a patient’s medication administration record (MAR), but they were not aware that they also needed to check pump settings and trace the tubing to the site of injection.

See Check It Out! [below] for recommendations to reduce the risk of mix-ups between epidural and IV routes of administration.

Check It Out! Consider the following suggestions to help avoid epidural and intravenous infusion mix-ups.

•Use special tubing. Only use special epidural tubing without injection ports for epidural infusions. Use of this tubing with restrictive access is a key error-prevention strategy that should be clearly described in all policies, procedures, and standard order sets related to epidural infusions. Place a neon "Epidural" sticker on the tubing (which is often included with epidural tubing).

•Build redundancy. Require an independent double-check of all epidural infusions at the bedside, and require nurses to trace the tubing from the source (infusion) to the insertion site (port) to verify the line attachment.

•Communicate. Establish a standard communication process for use when transferring surgical patients between preoperative, intraoperative, and postoperative care settings. Unusual circumstances, such as capped epidural catheters, should be described fully. See Special Announcements [on page 2 of this issue] for information about a tool kit to help with critical handoffs of surgical patients.

•Restrict privileges. Epidural infusions should only be started by practitioners who demonstrate ongoing competency (typically professional staff from anesthesia, PACU, labor and delivery, and certain critical care units).

•Segregate pumps. Place general IV pumps and epidural infusion pumps on opposite sides of the patient's bed to separate the two infusion systems. Use a different make or model of pump for epidural infusions to make them look different from IV pumps. Label the pump, "Epidural.” Avoid using dual-channel pumps for simultaneous administration of IV and epidural infusions.

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