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JCAHO Warns Health Care Organizations on Dangers of Tubing Misconnections

4/2006

The Joint Commission on Accreditation of Healthcare Organizations has issued a Sentinel Event Alert that urges healthcare organizations to pay special attention to how tubes and catheters are connected to patients. To date, nine cases involving tubing misconnections have been reported to JCAHO's Sentinel Event Database. These resulted in eight deaths and one instance of permanent loss of function. United States Pharmacopeia (USP) found more than 300 cases of misconnection errors reported to its databases.

Important warning signs of a possible misconnection include having to force-fit tubes together or having to use an adaptor. Using a tube or catheter for something other than its intended purpose also may signal, or cause, a misconnection.

The Alert includes risk reduction strategies and specific recommendations for health care organizations to reduce tubing misconnection errors.

The Alert is available at the Joint Commission on Accreditation of Healthcare Organizations Website.

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