Feeding tubes, intravascular catheters, and other tubes and lines are routinely and safely used in healthcare, but tubes or lines that become dislodged can have fatal consequences, depending upon the type of tube or line used and how quickly the dislodgement is recognized and treated. But are some dislodged tubes and lines more harmful than others? Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to answer this question and others.
In March 2017, the Authority published an analysis of 1,858 gastrostomy tube events reported through PA-PSRS from 2011 through 2015. Analysts identified dislodgement as the most frequently reported problem, described in 996 reports. Of these, 73 (7.3%) were reported as Serious Events resulting in patient harm, including nine deaths.1
Analysts reviewing these events questioned whether other dislodged tube and line types were reported to the Authority and how reports for dislodged gastrostomy tubes compared with these other types of tubes and lines, in terms of the number of events, severity of patient harm, and potential causes for dislodgement.
Analysts queried the PA-PSRS database for events involving dislodged tubes and lines that were reported in 2015. Events were identified using the following search criteria: (1) event subtypes included a catheter or tube problem, or removal of a tube or other medical device by a patient; (2) event descriptions contained the term “self remove” or derivative terms such as removed, removal, or removing; or (3) event descriptions contained terms used to describe tubes and lines in combination with terms to describe dislodgement. Terms used to describe tubes and lines included: catheter, drain, line, stent, tube, gastrostomy, PEG, mickey, button, jejunostomy, gastrojejunostomy, nasogastric, nasoduodenal, nasojejunal, orogastric, Dobhoff, Moss tube, Entec, intravenous, PICC, Medcomp, Broviac, port, Cordis, trach, ETT, or Hemovac. Terms used to describe dislodgement included deflate, disconnect, discover, dislodge, dislocate, displace, fell out, found, insert, leak, loose, lying, laying, misplace, malposition, move, out, patient pulled, patient pulling, position, place, pull, pull out, or tip. Wildcard characters and abbreviations were used in the search to include variations and misspellings of tube names. Harm scores for events were assigned by facilities at the time of reporting. (A list of harm scores and their definitions is available from the Authority.)
Analysts reviewed all reports to: (1) eliminate reports that did not involve a dislodged tube or line, (2) classify tubes and lines into six categories according to body system or placement: vascular, gastrointestinal, pulmonary, urinary, surgical and wounds, and cerebrospinal, (3) identify specific tube and line types according to anatomic location and/or function (e.g., nasally inserted enteral access devices, peripheral intravenous catheters, indwelling urinary bladder catheters, surgical-site drains), (4) tabulate harm scores reported for all dislodged tube events, and (5) identify potential causes for tube dislodgement included in the event descriptions.
The query produced 8,067 event reports; 4,583 were excluded because they were unrelated to the scope of the query, leaving 3,484 events confirmed to involve dislodged tubes and lines. Figure 1 shows the harm scores reported for these events.
The majority of dislodged tubes and lines were reported as Incidents (harm scores A through D), without harm to patients (n = 3,377, 96.9%). Of these, 91 reports were submitted for events considered as not reaching the patient (i.e., harm scores A, B1, and B2). Analysts reviewed each of these reports a second time and confirmed that a dislodged tube or line was involved in each of these events.
The following are examples of events involving dislodged tubes or lines reported through PA-PSRS, assigned different harm scores.*
Harm Score B2 – An event occurred, but it did not reach the individual (“near miss” or “close call”) because of active recovery efforts by caregivers:
The patient had been restless and was found with her tracheostomy ties untied and the tracheostomy tube three fourths of the way out of her neck. The tracheostomy tube was easily reinserted and the patient did not sustain an injury as a result of this event. The patient's medical provider and the patient's family were made aware.
Harm Score D – An event occurred that required monitoring to confirm that it resulted in no harm and/or required intervention to prevent harm:
The patient yelled out in room for help. Staff responded and the patient was noted to be attempting to get one leg over the side of the bed. When repositioned safely in bed, the urinary catheter was noted to be removed entirely with the balloon intact and stat-lock in place.
Harm Score F – An event occurred that contributed to or resulted in temporary harm and required initial or prolonged hospitalization:
The patient had a pleural catheter placed after developing subcutaneous emphysema following pacemaker implantation. The patient became confused and pulled out the catheter. A chest tube was placed for pneumothorax.
Harm Score I – An event occurred that contributed to or resulted in death:
The patient underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement without complications. Four days later, he was noted to have increased abdominal distension and hypotension requiring vasopressors. A computerized tomography scan showed the PEG tube terminating outside the gastric lumen, with pneumoperitoneum. The patient underwent emergency surgery, including closure of the gastrostomy site and abdominal washout. Following surgery the patient continued to decline. The patient was made comfort care and passed away the next day.
The top three categories of dislodged tubes and lines identified in event reports were vascular (n = 1,189), gastrointestinal (n = 1,064), and pulmonary (n = 1,015); see Table 1.
|TUBES AND LINES||INCIDENTS||SERIOUS EVENTS||TOTAL (%)|
Peripheral intravenous catheters
Peripherally inserted central venous catheters
Centrally inserted central venous catheters
Dialysis access catheters and needles
Implanted central venous port access needles
Central venous introducers and sheaths
Pulmonary artery catheters
Transvenous pacer wires
Central venous pressure monitoring lines
Extracorporeal cannulae and intraaortic balloon pumps
Nasally inserted enteral access devices
Surgically placed enteral access devices
Orally inserted enteral access devices
Enteral access devices - tube types not specified
Tracheostomy and laryngectomy tubes
Indwelling urinary bladder catheters
Nephrostomy and urostomy tubes
1 (< 0.1)
Surgical and Wounds
Surgical-site drains (bulb and accordion style)
Miscellaneous surgical and wound drains
Intracranial drains and catheters
Spinal drains and catheters
Note: Data submitted to the Pennsylvania Patient Safety Authority in 2015.
* Some event report narratives
described more than one dislodged tube or line, within and across categories;
therefore, the number of dislodged tubes and lines exceeds the total number of event
Analysts identified 29 types of tubes and lines described in the event narratives. Nasally inserted enteral access devices (i.e., nasogastric, nasoduodenal, nasojejunal tubes) were the dislodged tube type most frequently reported to PA-PSRS, followed by endotracheal tubes and peripheral intravenous catheters. Figure 2 shows the top types of dislodged tubes and lines.
Surgically placed enteral access devices (e.g., gastrostomy tubes and buttons, jejunostomy tubes) were the dislodged tubes most frequently identified in reports for Serious Events resulting in patient harm (n = 31 of 107, 29.0%), followed by peripherally inserted central venous catheters (PICCs; n = 14, 13.1%) and centrally inserted central venous catheters (e.g., non-tunneled and tunneled intravenous catheters; n = 13, 12.1%). Figure 3 shows the top types of dislodged tubes and lines identified in Serious Event reports.
Patients pulling on or moving tubes and lines was the most frequently reported potential cause for tube dislodgement, identified in about half of reports (n = 1,772 of 3,484, 50.9%). See Table 2 for a full list of potential causes for dislodgement identified in the event narratives.
|Potential Causes for Dislodgement||Reports (%) †|
|Patient pulling on or moving the tube||1,772 (50.9)|
|Movement of the tube during patient transfer, repositioning, or other care||578 (16.6)|
|Patient fall||206 (5.9)|
|Inadequate securement||119 (3.4)|
|Increased intra-abdominal pressure (i.e., coughing, sneezing, crying, vomiting)||74 (2.1)|
|Balloon deflated or ruptured||46 (1.3)|
|Tubing broken or ruptured||2 (0.1)|
|No reason reported||760 (21.8)|
Note: Data submitted to the Pennsylvania Patient Safety Authority in 2015.
* Potential causes for tube and line dislodgement were identified through qualitative analysis of event-report narratives.
† Some event narratives described more than one potential cause for dislodgement; therefore, the number of events totals more than 3,484, and the total percentage exceeds 100.
* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.
Pennsylvania healthcare facilities have reported patient safety events involving dislodged tubes and lines across a variety of categories and tube types. Although the vast majority of these events were reported as Incidents without patient harm, Serious Events have been reported that resulted in patient harm up to, and including, death. Dislodgement of surgically placed enteral access devices (including gastrostomy tubes) is of particular concern, compared with other tube types, representing 30% of the Serious Events reported. Patients pulling on or moving tubes and lines is the potential cause for dislodgement most frequently identified in event reports to the Authority. Hospitals seeking to avoid this adverse event are encouraged to implement risk reduction strategies to prevent, recognize, and manage dislodgement—such as those shared in the Authority’s March 2016 Pennsylvania Patient Safety Advisory article, "Dislodged Gastrointestinal Tubes: Preventing a Potentially Fatal Complication."1
- Feil M. Dislodged gastrointestinal tubes: preventing a potentially fatal complication. Pa Patient Saf Advis. 2017 Mar;14(1):9-16. Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/201703_dislodgedGI.aspx