Prevention of Tubing Misconnections Policy

Downloadable Version of Policy





Provision of Care, Treatment and Services


Prevention of Tubing Misconnections


Reviewed 01/23

Governing Body Approval:



PURPOSE: Hospital will practice safe standards related to the use of medical tubing.

SCOPE: All Clinical Staff



Hospital employs various types of medical tubing to support the care of patients. The improper connection of tubing systems can result in significant harm to patients. This procedure delineates processes designed to ensure that tubing connections are properly checked to prevent treatment errors. All clinical staff has a role in maintaining the integrity of tubing systems used to support clinical care. Family and visitors should also be educated on the need to promptly inform staff if any tubing connection fails or separates to ensure that the connection is properly re-established.



  1. Tubing misconnections are tubes, cables, or other hospital equipment connected to the wrong port which may result in patient injury or death.
  1. Tubing or catheters (for the purpose of this policy) may include but are not limited to: Feeding Tubes, Bladder (Foley) Catheters, Nasogastric Tubes and Tubing Peritoneal Dialysis Catheters, Bulb Drain Tubing (Jackson-Pratt), and Oxygen Tubing.
  1. Near Miss a misconnection that is recognized immediately and This results in no harm to the patient.
  1. Trace the process of tracking or following a tube or catheter from the patient to the point of origin.
  1. Luer Lock a connective device or syringe that can accept and allow many Due to the ease of connection, there may be no immediate indication that the connection is wrong.
  1. Medical Line Organizer is a product such as the Beata Clasp that facilities the bedside care giver and patient to manage tubing, lines, and cords by keeping them arranged in an aligned fashion preventing entanglement.



    1. Nursing staff should trace all lines back to their point of origin before making a connection. This process should occur:
      1. At time of admission to the unit and whenever they return from an off unit activity or procedure.
      2. Whenever nursing care is delivered which requires tubing to be disconnected.
  1. Never force a connection.
    1. If a connection is difficult it may be an indication that it is incorrect.
    2. Never tape a connection to make it work.
    3. Stop and ask for help.
  1. Do not use adaptors unless they are clearly required for the application.
    1. Adaptors may permit the connection of two inappropriate components.
  1. Inform all non-clinical staff, patients, and their families that they must get help from the nursing staff whenever there is a real or perceived need to connect or disconnect devices.
  1. Use only bulb syringes for oral or enteric feeding, never a Luer Lock device.
  1. Label all high risk catheters (i.e. peritoneal dialysis catheters).
  1. Always turn on the light in a darkened room before attempting to connect or re-connect tubing.
  1. Whenever possible routes tubes and catheters with alternate purposes in different directions.
  1. Implement a medical line organizer to maintain line separation and visualization.
  1. Report all near misses and discovered tubing misconnections through the nursing supervisory chain.
  1. Never use tubes, catheters, or connectors for unintended purposes.
  1. All new equipment should be evaluated by the hospital safety (EC) committee before being employed for patient care.

Who uses it:

Hospitals, intensive care units (ICU), medical-surgical units, neonatal units, labor and delivery units, emergency rooms, pediatric units, outpatient surgery centers, dialysis centers, home health, hospice, private home use, sleep apnea centers, nursing homes, quick care centers, and in ambulances.

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