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Reduce Adverse Drug Events (ADEs) Involving Intravenous Medications:
Label All Distal Ports and Tubing on All Lines

Patients may sometimes have multiple lines in place. These may include peripheral intravenous lines, central lines and nasogastric tubes. Unfortunately, the ports on all of these are often the same size, which makes it very easy for staff to connect a syringe to the wrong port. In addition, the tubing and distal ports are often very close to each other. This can lead to oral medications being injected or tube feedings being connected into intravenous lines, either of which can lead to a serious adverse event. Placing labels on each distal port helps staff to identify the correct line when administering items or connecting tubing. Make sure to label the tubing as well, so that if it is disconnected from the port, whether by accident or intentionally, it is clear which connections match up.


Tips
  • Use labels that look different for each type of line, distinguished by color or size. Remember, though, that some staff may be color-blind.
  • Conduct independent double-checks and include checking line connections in the process.