Health Care Providers:
ACT to prevent tubing misconnections! To help reduce risk to patients, consider the following strategies, based on recommendations from The Joint Commission1 and ECRI Institute2, an independent nonprofit that researches the best approaches to improving patient care.
- Assess and clearly label each device, including low-risk devices and high-risk catheters.
- Ensure good communication between health care staff during patient transfer.
- Inform non-clinical staff, patients, families, and caregivers they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or tubing.
- Trace a tube from the patient to the point of origin prior to connecting any new devices or replacing old ones.
- Vigilantly check and recheck Luers to ensure proper connections prior to each use.
Risk managers, nurse managers, clinical educators, and similar personnel may consider taking the following steps to help prevent misconnections:
- Tell clinicians, patients and caregivers in home-based or ambulatory care when new devices are intended for use in the health care facility or home health agency.
- Emphasize the risk of tubing and catheter misconnections in orientation and training.
Health Care Facilities:
ECRI Institute recommends that facilities create a multidisciplinary task force—with staff from nursing, risk management, clinical engineering, and purchasing—to identify potential misconnections hazards and develop strategies for combating them3. Consider the following actions to help prevent misconnections:
- During initial use, check new devices and equipment to identify potential misconnections and take immediate corrective actions, if necessary.
- Report adverse events and near misses, following your facility protocol.
- Report any issues to the FDA through its MedWatch reporting system.
- Health care personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.
1 Joint Commission. April 3, 2006. Sentinel Event Alert. “Tubing Misconnections—a persistent and potentially deadly occurrence.” Issue 36. http://www.jointcommission.org/assets/1/18/SEA_36.PDF (PDF - 31KB)
2,3 ECRI Institute. March 2006. Health Devices. “Preventing Misconnections of Lines and Cables.” Volume 35, Number 3, pages 81-95. https://www.ecri.org/Documents/Patient_Safety_Center/Preventing_Misconnections_of_Lines_and_Cables.pdf (PDF - 387KB)