The Joint Commission issues a sentinel event alert emphasizing what health care organizations can do to prevent errors in tubing connections (such as connecting a feeding tube to an intravenous system).Sentinel Event Alert. August 20, 2014;(53):1-6.
Managing risk during transition to new ISO tubing connector standards.
Sentinel Event Alert. August 20, 2014;(53):1-6.
The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubingconnectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.
Le-Abuyen S, Ng J, Kim S, et al. Am J Infect Control. 2014;42:439-442.
Strassels SA. AHRQ WebM&M [serial online]. August 2006.
COMMENTARYView all related resources...
Kayser SR. AHRQ WebM&M [serial online]. February 2007.