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Wrong Route for Nutrients

Jill R. Scott-Cawiezell, RN, PhD | July 1, 2008
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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 environment.

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 RNs).(4) 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 staffing.(7) 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 implications.

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 activities.

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 systems.

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 (gastrointestinal).
  • 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


1. Leape L. Lucian Leape on patient safety in U.S. hospitals. Interview by Peter I. Buerhaus. J Nurs Scholarsh. 2004;36:366-370. [go to PubMed]

2. Leape L. Is hospital patient care becoming safer? A conversation with Lucian Leape. Interview by Peter I. Buerhaus. Health Aff (Millwood). 2007;6:w687-w696. [go to PubMed]

3. Scott-Cawiezell J, Vogelsmeier A, McKenney C, et al. Moving from a culture of blame to a culture of safety in the nursing home setting. Nurs Forum. 2006;41:133-140. [go to PubMed]

4. Vogelsmeier A, Scott-Cawiezell J, Zellmer D. Barriers to safe medication administration in the nursing home—exploring staff perceptions and concerns about the medication use process. J Gerontol Nurs. 2007;33:5-12. [go to PubMed]

5. Scott-Cawiezell J, Rantz M, Hicks L, et al. Technology to improve medication safety in nursing homes. Final Report to Agency for Healthcare Research and Quality; 2007.

6. Scott-Cawiezell J, Pepper G, Madsen RW, et al. Nursing home error and level of staff credentials. Clin Nurs Res. 2007;16:72-78. [go to PubMed]

7. Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc. 2006;7:366-376. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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