Medication given through an unintended route is a very serious form of medication error. The three-way stopcocks are universally used in different tubing systems across health care. They are used in several routes of administration for parenteral and enteral fluids as well as invasive pressure monitoring and drainage tubes. Lack of proper labeling and differentiation is the perfect setup for a system failure and serious adverse events. Accidental intra-arterial injections of medications intended for intravenous use, have resulted in severe ischemia, limb loss, disability and death of many patients. Fasciotomy or ultimately amputation may result from a medication error. To prevent accidents a well visible labeling system is necessary. The LineSHELL provides a color-coded based system to label and differentiate what type of route the three-way is placed into.
Malpositioning of the three-way stopcock lever can result in flow blockade, blood loss (exsanguination) or leakage of fluid and medication outside of the IV tubing. The blockade can result in loss of intravenous access or a-line measurements. This problem is particularly pertinent is situations when direct access to the three- way is not available, such as in the operating room where IV sites and connectors can be covered under the drapes or in the imaging suite where the provider is away from the patient. In either case, the ongoing procedure must be interrupted to address the three-way issue. LineSHELL prevents all these problems. Currently, providers wrap the three-way with adhesive tape. The adhesive from the tape increases the risk of bacterial contamination and waste precious operating room time.
On average the three-way connectors are manipulated between 10 to 30 times a day. One in every three stopcocks gets contaminated in the first day of patient’s admission due exposure to hospital environment or manipulation by the health care providers. Once germs contaminate the hub, they are flushed into the IV tubing and circulation potentially causing central line associated blood stream infections (CLABSI).
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