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Difficulty: MediumAccident, Error, and Injury Prevention

A nurse is assuming care for a confused older adult client who has just been transferred from the intensive care unit to the medical-surgical unit. The client has a peripheral intravenous (IV) line infusing fluids, a nasogastric tube for continuous enteral nutrition, and a continuous bladder irrigation catheter. To prioritize accident and error prevention during the handoff, which of the following actions should the receiving nurse perform first?

  1. Trace all tubes, lines, and catheters from the client to their respective infusion pumps or drainage receptaclesAnswer
  2. B
    Apply bilateral soft wrist restraints immediately to ensure the client does not pull out the invasive lines
  3. C
    Direct the unlicensed assistive personnel (UAP) to verify that the enteral feeding is infusing at the prescribed rate
  4. D
    Empty the urinary drainage bag and document the amount to establish an accurate baseline for shift output

Answer

The receiving nurse should first trace all tubes, lines, and catheters from the client to their respective infusion pumps or drainage receptacles to prevent tubing misconnections.
Tracing all lines from the client to the equipment is a critical safety practice recommended by national safety guidelines to prevent tubing misconnections. During transitions of care, verifying that IV fluids, enteral nutrition, and irrigants are connected to the correct ports prevents potentially fatal administration errors.

Step-by-Step Solution

1
Identify the primary safety risk for a client with multiple invasive lines transferring between units.
The highest risk is a tubing misconnection, such as infusing enteral nutrition into an IV line.
Transitions of care are high-risk periods for medical errors, especially when multiple continuous infusions and drainage systems are present.
2
Determine the highest priority nursing intervention to mitigate this specific risk.
Line tracing is established as the priority.
National patient safety goals mandate tracing all lines from the origin (the client) to the connection ports and infusion pumps immediately upon assuming care to ensure correct routing.
3
Evaluate the other options against the priority safety action.
Restraints require alternative attempts first, verifying infusions cannot be delegated, and emptying a drainage bag is routine care.
Immediate physical safety and error prevention always supersede routine documentation, inappropriate delegation, and premature use of restraints.

Key Concept

Prevention of Medical Errors and Tubing Misconnections
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Topics

Accident, Error, and Injury Prevention

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