Cases & Commentaries

Wrong Route for Nutrients

Commentary By Jill R. Scott-Cawiezell, RN, PhD

The Case

An 82-year-old man living in a skilled nursing
facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and developed several decubitus ulcers
on his coccyx and hips that were not healing. He was diagnosed with
failure to thrive and was fed using a percutaneous enterostomy
tube. This treatment did not bring about improvement in his
condition. To provide more nutrition, the physician placed a
central venous line and prescribed intravenous (IV) total
parenteral nutrition (TPN) administration.

In the SNF, licensed practical nurses (LPNs)
administer most medications. The LPN on the night shift mistakenly
hooked up the total nutrient fluid prepared for the central line
(i.e., to be delivered as IV TPN) to the enterostomy tube. The
patient's daughter was in the room and observed this error. She
questioned the LPN about this procedure, and the LPN told her that
this was what had been ordered. But just to be sure, the LPN
checked with the registered nurse (RN) in charge and learned that
the daughter's concern was well founded—indeed this total
nutrient fluid was to be administered through the central line, not
through the enterostomy tube.

Recognizing the mistake, the LPN returned to the
patient's bedside to correct the error, disconnected the total
nutrient line from the enterostomy tube, and prepared to connect it
to the central line catheter. Fortunately, both the daughter (a
retired RN) and the RN in charge were present and stopped the LPN
from contaminating the central line with this line that had been
directly communicating with the patient's bowel. The total nutrient
solution was discarded, and the physician was notified. The next
total nutrient fluid preparation did not arrive until the following
evening. Therefore, the patient did not receive this supplemental
nutrition for 24 hours.

The Commentary

We interpret reports of
medical error through the prism of our own underlying assumptions
and professional biases. Despite our ability to intellectualize
that "it's the system," many still look to the individuals involved
and, consciously or unconsciously, cast blame.(1,2) In long-term care, this tendency to cast blame and
seek quick fixes is further exaggerated by our knowledge that the
setting tends to suffer from limited resources, overwhelmed
leadership, and an educationally diverse workforce.(3)
The goal is
to move from casting blame to carefully identifying and managing
risk and creating a culture that attends to both systemic problems
and an individual's accountability for the provision of a safe

Medication administration in the long-term
care setting is often viewed as a routine task, while in reality
the administration of medications to frail and elderly patients
reflects a complex interaction of many decisions and actions, which
are often performed by staff with variable levels of education
(such as certified medication technicians [CMTs], LPNs, and
In a recent 2-year AHRQ study of five nursing homes,
medication error rates among staff representing diverse levels of
education were explored. In the review of almost 16,000 medication
administrations, there was no difference in medication error rates
across RNs, LPNs, and CMTs (5,6)
, perhaps indicating that the
varied workforce is not a major issue. On the other hand, a
systematic review found many inconsistencies among measures of
quality that were associated with the composition of nursing home
Whatever the research findings, what is clear is that
RNs, LPNs, and nursing assistants have different skills, and
planning for safe care with these different staff members remains
an ongoing challenge with clear safety and cost

In the current case study, role clarity, safe
systems, and individual responsibility are all at issue. In terms
of role clarity, one characteristic of safe systems is that there
is a clear understanding of the education and the role of the
various care providers, in this case the RN and the LPN. While the
training, rules, and statutes related to the LPN role vary across
states, LPNs all take the same licensure exam. Typically, an LPN
would receive approximately 30 hours of didactic and skills lab
training to become certified in placing and managing IV lines. This
could be in addition to or as a part of their basic training (12
months). On the other hand, RNs have a foundation in the basic
sciences, with chemistry, microbiology, and physiology as a part of
the prerequisite education before entering into clinical education.
This fundamental difference in foundational education provides
context for how RNs and LPNs differ in their ability to be
attentive to, and mindful of, the many critical elements of
providing care to frail and elderly patients. Thus, in most states,
RNs provide direct supervision when starting nutrients, and LPNs
may monitor and support the ongoing therapy. Considering the roles
of the RN and the LPN in the management of parenteral nutrients, in
this case the RN should have started the TPN. The LPN's role should
have been limited to monitoring the nutrients over the course of
the infusion.

Regardless of the level of education, people make
mistakes, and safe systems should be in place to minimize risk. Any
medication whose route could be confused must be clearly marked on
the bag and at the port to alert the staff to risk. In this
situation, the bag and the tubing should have been clearly marked
for IV USE ONLY. Additionally, the port of the IV tubing should not
be able to connect to enterostomy tubes and vice versa (a forcing
function). The facility should have had clear protocols for double
checking the initiation of TPN. Finally, the RN should have been
directly involved in the initiation of the therapy as a part of
standard procedure, even if the facility or state allowed LPNs to
hook up the IV tubing.

Building safe systems does not negate individual
accountability. In the current case, the LPN, although shaken by
the error, should have known the implications of simply moving the
nutrients from a clearly contaminated port to a sterile port. All
LPNs should have had the technical training to understand the
basics of aseptic technique. While it can be argued that the LPN
was not attempting to be reckless with her behavior since there was
no evidence of intentional disregard of the risk of harm, she was
exhibiting at-risk behavior where she likely "drifted away" from
the correct procedure. Through a just culture lens, the LPN did
require appropriate coaching and additional training. Further, the
incident highlighted potential risks for all staff and identified
the need for training to reduce the potential for future error.

One positive aspect of the case is the culture of
safety as it pertains to communication and expressing concerns up
the authority gradient. The outcome could have been far worse if
the patient's daughter had not felt comfortable questioning the
LPN's procedure. Moreover, had the LPN become defensive, the
opportunity for risk mitigation would have passed. Instead, even
though she felt like she was doing the right thing, the LPN asked
the RN about the procedure and was told that the daughter's
concerns were well founded. In many ways, this level of
communication and questioning is admirable and might well reflect a
safe culture. The leadership of this long-term care facility should
highlight it as a "great catch" to encourage similar discussions
between families and staff and among staff members, even as it uses
the problems in this case as fodder for quality improvement

Although clearly there is individual
accountability here, there is also great opportunity to reflect on
a complex clinical process and to learn from the actual error and
the potential for additional error. Nursing homes are beginning to
move from casting blame to using situations such as these as
substrate for quality improvement efforts.(7) The challenge of providing long-term care to frail and
elderly patients is complex and requires a balance of fiscal
realities and careful management of risk. In resource-strained
environments, even more attention must be paid to the critical role
of the RN and the need for diligence in the development of safe

Take-Home Points

The case illustrates several key
points about medication safety in the long-term care setting,
particularly as it relates to IV therapy:

  • The roles of various providers need to
    be clear. Staffing levels and clear protocols must also be present
    to ensure that the right person is delivering the right level of
    care to the resident.
  • Equipment should be designed in such a
    way as to preclude the connection into systems that are clearly
    sterile (IVs) from systems that are nonsterile
  • Leaders should be well versed in
    assessing system issues and individual accountabilities with the
    capabilities to manage both types of risk.

Jill R. Scott-Cawiezell, RN, PhD
Associate Professor
University of Missouri-Columbia, Sinclair School of Nursing


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