Preventing accidental disconnections of lines connecting patients to medical devices

The Therapeutic Goods Administration (TGA) has received reports of haemodialysis catheters becoming dislodged at the Luer lock connection point. In some cases, the dislodgement was not detected, as the catheter and all connections were out of sight.

In a hospital setting, patients may have a number of lines connected to different devices; therefore, accidental disconnection of these lines can occur. It is possible for these lines to:

• become tangled
• be inadequately secured
• get caught on bedding, on other medical devices or in the fingers of the patient or health professional caring for the patient.

Accidental disconnections when a patient is connected to pumps and/or machines that operate using high flow rates (e.g. dialysis machines) can be fatal.

The TGA is providing the following safety information to assist health professionals with preventing the accidental disconnection of lines that connect patients to medical devices.

Recommended actions to prevent disconnections

• All staff responsible for patient lines and connectors must receive adequate training, including training on reducing the risk of accidental disconnection.
• All connection points should be adequately tightened prior to the commencement of treatment.
• All connection points should be visible and easily accessible.
• The use of fluid detection sheets under the connection points of haemodialysis lines should be considered.
• Policies and procedures that include regular monitoring of lines and connection points should be implemented to reduce the risk of disconnection of lines and to deal with any disconnection that does occur. These should include:
  1. Advising patients to seek help immediately if they become aware of a disconnection and not to attempt to re-connect the lines themselves.
  2. Using products that are designed to decrease the risk of disconnection.
  3. Avoiding forcing a connection. If a line is difficult to connect, it may mean that is was not meant to be connected.
  4. Improving handovers involving patients with multiple lines in place, particularly when transporting them, including a description of what each line and device is for, and where they connect.
  5. Reporting ALL disconnections to the hospital and /or the TGA.

Reporting adverse events

Health professionals and consumers are encouraged to report any problems associated with a medical device to the TGA via the Reporting problems link on the TGA Internet site. All information received contributes to the TGA investigation of potential safety issues.

Reports are investigated under the Medical device incident reporting and investigation scheme (IRIS).

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