Catheter and tubing misconnections occur “frequently and lead to deadly consequences in many instances,” according to a warning issued Monday by the Joint Commission on Accreditation of Healthcare Organizations. The healthcare quality group issued a rare “Sentinel Event Alert,” urging providers to pay special attention to the devices, while also challenging makers of the devices to redesign them to lessen the likelihood of dangerous misconnections.
Reports to the Joint Commission, ECRI, the Food and Drug Administration (FDA), the Institute for Safe Medication Practices, and United States Pharmacopeia detail the “frequent” misconnections, JCAHO said. “Thankfully, many tubing misconnections are caught before the patient is injured, but these errors pose a real threat to patient safety that can be overcome through heightened vigilance and a systematic approach to avoiding misconnections,” said Dennis S. O’Leary, M.D., president of JCAHO.
Important warning signs of a possible misconnection include having to force-fit tubes together or having to use an adaptor, JCAHO’s statement said. The group recommends, among other steps, always tracing a tube or catheter from the patient to the point of origin before connecting any new device or infusion.
Its full statement and list of recommendations can be found at www.jcaho.org.
