Table 9:

Setting Up and Programming Multiple Primary Continuous IV Infusions: Practice Issues in Exchanging Multiport Connectors

Hazard	Description	Frequencya
Exchanging the old multiport connector for the new one before attaching and starting all new drug infusions	Some participants attached the new multiport connector to the patient access port before attaching and running all the new infusions; this led to an interruption in life-sustaining therapies. In the baseline condition, some participants choose to reuse currently infusing pumps for the new infusions rather than using the spare pumps provided (in the one-at-a-time condition, participants were required to use the spare pumps to comply with the protocol). The reuse of pumps exacerbated interruptions in therapy, since existing infusions had to be stopped and dismantled before setting up new infusions	27 (38.0%)
Connecting the new multiport connector when it was full of sodium chloride 0.9%	Some participants attached the new multiport connector to the patient access port when the connector was primed with only sodium chloride 0.9% and did not contain a mix of the attached medications (i.e., infusions were not started and allowed to fill the connector prior to attaching it to the access port). This led to a temporary interruption in therapies while the sodium chloride 0.9% was pushed through the multiport connector and into the patient (see Theme 3: Managing Dead Volume)	13 (18.3%)
Forgetting to unclamp the patient catheter after attaching the new multiport connector to the patient	Participants typically clamped the access port on the patient catheter when the old multiport connector and infusions were removed to prevent air embolism, venous backflow into the catheter, and infection (Figure 8). However, some participants failed to open the clamp once the new multiport connector was attached to the access port. Consequently, there was likely an interruption in all therapies (rate-dependent). A downstream occlusion alarm would eventually have been triggered on the infusion pumps, which would have helped participants identify and recover from this hazardb	5 (7.0%)
Exchanging the wrong old multiport connector (and attached infusions)	One participant disconnected the wrong multiport connector (i.e., the one on access port 1 instead of the one on access port 3, Figure 8). Consequently, the new multiport connector with the new infusions was attached to the wrong access port. As a result, the patient received some infusions twice (i.e., an overdose of infusions 1 to 4 in Figure 8), and others were disconnected (i.e., interrupted therapy of infusions 6 to 9 in Figure 8). This error may or may not have been identified by the participant during the dismantling of the old infusions	1 (1.4%)

Abbreviation: IV, intravenous.

^an = 71. The 71 line changes in the analysis included all line changes completed by participants in both the baseline and one-at-a-time conditions.

^bThe line change task was the last to be completed in the patient scenario. Since infusions were running at a low flow rate, the downstream occlusion alarm was not triggered, and participants’ ability to detect and remedy errors was not evaluated.