2 TheĪlert offers risk reduction strategies and recommendations, which are included in the overall risk reduction strategies below. Pharmacopeia (USP), including intravenous infusions connected to epidural lines and infusions intended for IV delivery connected to nasogastric tubes. TheĪlert also described misconnection events reported to U.S.
Sentinel Event Alert describes the types of tubing and catheter misconnections reported to Joint Commission, including central intravenous catheters, peripheral intravenous catheters, nasogastric feeding tubes, tracheostomy cuff inflation tubes, and automatic blood pressure cuff insufflation tubes. Sentinel Event Alert issued by the Joint Commission in April 2006. 1 However, misconnections have garnered more attention in recent years, especially in the United States, due in part to the tubing misconnection One of the earliest published reports of misconnections was the inadvertent delivery of breast milk via intravenous (IV) administration in 1972. Misconnections have been recognized as a serious problem for many years. Under these circumstances, tubing misconnections can occur with potentially fatal results. Medical devices connected to patients may also have tubing lines connecting the devices with other medical devices. Introductionĭepending on acuity level, patients may have many tubing lines connecting them to medical devices and/or for delivering medication or nutrition therapy. Administrative controls are policies and practices that reduce the risk of misconnections such as tracing lines back to their source.
Equipment design solutions either prevent the user from making a misconnection or prompt the user to make the correct connection. Methods for reducing the likelihood of tubing misconnections include equipment design solutions and administrative controls (policies and work practices). Between January 2008 and September 2009, 36 events of tubing misconnections were reported to the Pennsylvania Patient Safety Authority involving various types of misconnections. These connectors contribute to misconnections because they allow functionally dissimilar tubes or catheters to be connected together. One of the main reasons for tubing misconnections is that many types of tubing for different types of medical devices incorporate luer connectors. Tubing misconnections can occur with intravenous catheters, feeding tubes, hemodialysis tubes, and tracheostomy cuffs, among other devices. With these multiple lines, the potential for tubing misconnections becomes more prevalent. Some patients may have multiple tubing lines connected to them for reasons such as delivery of medication and nutrition therapy.
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