Tubing misconnections: making the connection to patient safety
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Equipment Design -- adverse effects Equipment Safety Medical Errors -- prevention & control Safety Management -- methods Catheterization -- adverse effects Catheterization -- instrumentation Drug Delivery Systems -- instrumentation Enteral Nutrition -- adverse effects Enteral Nutrition -- instrumentation Equipment and Supplies, Hospital Infusions, Intravenous -- adverse effects Infusions, Intravenous -- instrumentation Intubation -- adverse effects Intubation -- instrumentation Materials Management, Hospital Humans United States
- Genre(s):
- Technical Report
- Abstract:
- Some patients may have multiple tubing lines connected to them for reasons such as delivery of medication and nutrition therapy. With these multiple lines, the potential for tubing misconnections becomes more prevalent. Tubing misconnections can occur with intravenous catheters, feeding tubes, hemodialysis tubes, and tracheostomy cuffs, among other devices. One of the main reasons for tubing misconnections is that many types of tubing for different types of medical devices incorporate luer connectors. These connectors contribute to misconnections because they allow functionally dissimilar tubes or catheters to be connected together. Between January 2008 and September 2009, 36 events of tubing misconnections were reported to the Pennsylvania Patient Safety Authority involving various types of misconnections. Methods for reducing the likelihood of tubing misconnections include equipment design solutions and administrative controls (policies and work practices). Equipment design solutions either prevent the user from making a misconnection or prompt the user to make the correct connection. Administrative controls are policies and practices that reduce the risk of misconnections such as tracing lines back to their source.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101546438 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101546438