Medical line entanglement: The unspoken patient safety hazard of medical devices

Abstract

In February 2022, the US Food and Drug Administration published a safety communication regarding the risk of strangulation from enteral feeding delivery sets. When it comes to the causes of accidental strangulation or asphyxiation, it is common knowledge that household items, such as window blind cords, are potential hazards. However, many people may not expect that medical devices may pose similar risks because of medical line entanglement (MLE). A survey of clinicians from pediatric acute care and outpatient facilities and caregivers of patients with medical lines was conducted with a goal to understand if clinicians and caregivers are aware of MLE, if healthcare facilities have policies and procedures related to the prevention of MLE, and if education about the risks of MLE is provided to caregivers when they first receive a medical device. The survey was shared through clinician organizations and patient advocacy groups. Responses were received from 191 clinicians and 117 caregivers. A majority of clinicians reported awareness of the risk of entanglement; however, few received direction from their employer on managing these risks. Caregivers (N = 106) reported that their child had experienced MLE, however only 9% of those caregivers recalled receiving any education on MLE from their healthcare providers. This survey demonstrates the need for healthcare facilities to develop programs for managing risks of MLE and for healthcare teams and caregivers to discuss prevention methods whenever an at-risk patient is sent home with a medical device that poses a risk for entanglement.