Abstract :

This study focuses on measures taken to prevent catheter and tubing misconnections at KG Hospital and the Postgraduate Medical Institute. A systematic DMAIC methodology approach identified high-risk misconnections and implemented a comprehensive action plan. The interventions included the elimination of design flaws, the introduction of alternative sets, and the implementation of a colourcoded labelling system. Regular audits and project reviews were conducted to ensure sustainability and scalability. The successful pilot in the Cardiothoracic and Vascular Surgery department demonstrates the potential for adoption in healthcare institutions nationwide, contributing to improved patient safety.

Organizational Profile:

KG Hospital & Postgraduate Medical Institute, located in Coimbatore, was established in 1974 as a trust hospital with the vision of providing advanced and affordable healthcare to all. Our Founder- chairman, Padmashri Dr G. Bakthavathsalam, has been instrumental in shaping this institution.

KGH Postgraduate Medical Institute has successfully trained over 300 doctors, earning recognition and a national award for its excellence in teaching from the National Board of Education. Quality is our top priority at KGH, and we have received various certifications and accreditations, including 55 certification, ISO 9002, NABL accreditation, and NABH accreditation, since 2010.

We take pride in achieving several milestones in medical innovation. KG Hospital was the first hospital in Asia to install a 128-slice CT scan, introducing cutting-edge technology for accurate diagnosis. We also pioneered the world’s first 4D wireless ultrasound system, revolutionizing the field of ultrasound imaging. Furthermore, KG Hospital is distinguished by performing the first awake open- heart surgery in India and providing dialysis to a two- day-old baby for the first time in the country. Additionally, we were the first hospital in Coimbatore to perform minimally invasive cardiac surgeries, offering advanced treatment options to our patients.

At KG Hospital & Postgraduate Medical Institute, we remain committed to delivering high-quality healthcare services while embracing innovation and setting new benchmarks in the medical field.

Introduction:

The implementation of the project followed the guidelines of the BAXTER Tubing Misconnections Self-Assessment for Healthcare Facilities. Top-level management actively participated in the project process, from the initial definition phase to the control phase. The project team comprised professionals from various disciplines, including doctors, nurses, technicians, clinical pharmacists, and the quality team, ensuring a multidisciplinary approach to address tubing misconnections effectively.

Tubes and catheters play a crucial role in delivering essential healthcare services daily. Critically ill patients often have multiple tubes and catheters connected to them, serving various purposes such as medication administration, food intake, and intravenous therapy. In a recent incident at our hospital, a nurse came close to misconnecting the tubes, but fortunately, a senior nurse intervened and prevented a potential crisis. The problem was promptly identified and effectively managed by our vigilant team.

To find out the nature of the problem, the following measures were taken:

1. The project followed the DMAIC methodology, consisting of the Define,Measure, Analyze, Improve, and Control phases.
2. A descriptive study examined the potential for misconnection among tubes and catheters in the hospital.
3. Forty-six commonly used tubes were categorized, and 2070 possibilities of connections/misconnections were identified.
4. Each connection possibility was assigned a risk priority number, calculated based on the ease of connection and potential harm.
5. A risk priority number of 25 indicated a high-risk misconnection that could result in patient death.
6. Sixty-three connections were classified as high-risk based on their assigned risk priority numbers.
7. A fishbone analysis was performed to identify the challenges contributing to the high-risk connections.
8. Challenges included multiple tubes for patients, similar device designs, lack of tube reconciliation adherence, untrained staff, and involvement of patient attendees in handling tubes.
9. The similar design of devices was identified as the most significant challenge and contributor to the misconnection problem.

An action plan was implemented to address the design flaw contributing to misconnections. Firstly, Leur Slip IV and Blood sets, prone to misconnections, were eliminated. Instead, alternative sets that minimized the risk of misconnections were adopted.

Additionally, black piston syringes were explicitly introduced for tracheostomy procedures, ensuring clear differentiation and reducing the chances of incorrect connections.

Colour-coded labels were assigned to different tubes and catheters to enhance clarity. For example, arterial tubes were designated with a red code, while venous tubes were labelled in blue. This visual distinction aided in easily differentiating and identifying the tubes during medical procedures. A colour-coding system was initially implemented in the cardiac Intensive Care Unit (ICU) to assess its effectiveness as part of a pilot initiative.