What’s New in the Patient Safety World
April 2012
Tubing Misconnections
Catheter/tubing misconnections are among the most devastating patient events we have seen, since many result in patient death. See our previous columns on this topic:
July 10, 2007 “Catheter Connection Errors/Wrong Route Errors”
November 2007 “More Patient Deaths from Luer Misconnections”
August 2009 “Catheter Misconnections Continue to Occur”
August 2010 “ISMP Advice on Catheter Misconnections”
August 23, 2011 “Catheter Misconnections Back in the News”
A couple new resources to help prevent such accidents are now available. ISMP (ISMP 2012), in collaboration with Baxter Healthcare’s Clinical Center of Excellence, has developed a tubing misconnections self assessment for healthcare facilities. A brief tutorial can be accessed from ISMP’s website and the full assessment and tutorial can be accessed from Baxter’s Clinical Center of Excellence website.
The winter issue of the APSF newsletter has an article on preventing epidural catheter misconnections (Block 2012). It emphasizes the need for device redesign to prevent such errors. It has a good bibliography regarding incidents specifically related to injection of incorrect substances into the epidural space.
The general concepts of catheter misconnections and wrong route incidents were discussed in our previous columns noted above and in the 2006 Joint Commission Sentinel Event Alert #36, the UK NPSA, the WHO/Joint Commission Collaborating Center for Patient Safety Solutions, the October 2007 issue of FDA Patient Safety News and multiple ISMP articles.
References:
ISMP (Institute for Safe Medication Practices). ISMP Medication Safety Alert! Acute Care Edition 2012; Tubing Misconnections Self Assessment for Healthcare Facilities.
March 8, 2012
http://www.ismp.org/Newsletters/acutecare/issue.asp?dt=20120308
Brief tutorial
www.ismp.org/selfassessments/tubingMisconnections
Full assessment and tutorial www.baxter.com/healthcare_professionals/clinical_center_of_excellence/connections_portfolio/programs/tubing_misconnection_index.html
Block M, Horn RJ, Schlesinger MD. Reducing Risk of Epidural-Intravenous Misconnections. APSF Newsletter 2012; 26(3): 63-66 Winter 2012
http://www.apsf.org/newsletters/pdf/winter_2012.pdf
The Joint Commission. Tubing misconnections—a persistent and potentially deadly occurrence. Sentinel Event Alert 2006; Issue 36 April 3, 2006
http://www.jointcommission.org/assets/1/18/SEA_36.PDF
World Health Organization, The Joint Comission, Joint Commission International: WHO Collaborating Centre for Patient Safety Solutions. Avoiding catheter and tubing mis-connections. Patient Saf Solut. 2007; Volume 1. Solution 7. May 2007
http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution7.pdf
National Patient Safety Agency (UK). Patient Safety Alert “Promoting safer measurement and administration of liquid medicines via oral and other enteral routes” March 28, 2007 http://www.npsa.nhs.uk/site/media/documents/2463_Oral_Liquid_Medicines_PSA_FINAL.pdf
FDA. More Patient Deaths from Luer Misconnections FDA Patient Safety News: Show #68, October 2007
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=567
ISMP. Collection of all their catheter misconnection articles.
http://www.ismp.org/newsletters/acutecare/articles/Catheter-Misconnections.asp
http://www.patientsafetysolutions.com/
What’s New in the Patient Safety World Archive