While bathing a patient, a member of the nursing staff accidentally connected I.V. tubing to the inflation port of the patient's tracheostomy cuff. (The port is usually compatible with both slip-tip and luer-lock syringes for inflating the cuff.) Normally, the patient wore a gown with sleeves that snapped closed, but on this day he was wearing a gown without snaps. The person bathing him disconnected his I.V. tubing from a luer connector and threaded it through the sleeve, then mistakenly connected it to the luer connection on his tracheostomy cuff inflation port.

Fluid entered the cuff, and the patient began to have trouble breathing and became cyanotic. The I.V. line was immediately disconnected from the cuff and approximately 30 mL of fluid was removed. The patient quickly recovered.

Until inflation and infusion ports are designed to be incompatible, consider the error-reduction strategies described here.

Identify the potential for errors when introducing new tubes, catheters, and connectors, and with existing tubing.

Get appropriate education before you use any new type of tube, catheter, or connector. When possible, tubing misconnections should be simulated and discussed during orientation and annual safety competencies.

Permit only staff members with appropriate professional health care education to connect, disconnect, and reconnect tubing.

Label lines near the insertion site when a patient has more than one port of entry into the body, including I.V., arterial, umbilical, enteral, bladder, tracheostomy, and drainage tubes.

Develop and use a consistent process for tracing all lines from the source to the connection port to verify attachments before connecting or reconnecting tubing or administering drugs, solutions, or other products.

Monitor patients appropriately to detect errors quickly and minimize the consequences of errors.