Nurses' understanding of tubing misconnections between enteral and intravenous systems: A multiple case, explanatory, grounded theory study

The simple act of connecting two tubes seems minor in the complex healthcare system of today. However, the seemingly mundane can quickly turn tragic in healthcare. Misconnecting an enteral system (meant to deliver nutrition to the gastrointestinal system) to an intravenous system (meant to deliver fluids and medications intravenously) has often resulted in death of the patient. In this study, exploring nurses' understanding of misconnecting an enteral system to an intravenous system, served as a way to better understand healthcare safety and nurses' understanding of tubing misconnections. The findings reflect nurse's awareness of their work environment, the equipment they work with, and safety and factors that contribute to errors. Insight into nurses understanding of tubing misconnections may provide guidance for preventing tubing misconnections and other errors in patient care.

Grounded theory methodology was used to answer the question “what do nurses understand about tubing misconnections between enteral and intravenous systems?” Direct care nurses with experience in connecting enteral and intravenous tubing participated in a highly interactive interview. Two groups contributed to and validated the findings, institutional level quality and safety professionals and safety experts.

The study findings suggest that applying both systems analysis of errors and focusing on cognitive load will lead to effective actions for preventing healthcare errors. The singular data elements of the findings point to usual routine occurrences within the daily practice of nursing that can go unremarked and be trivialized when observed independently. However the aggregate data supports a view of a hazardous stressful workplace where accumulative cognitive load, policy, culture, environment, and a deceptively simple device can result in patient death.