Tubing Misconnection Errors Widely Recognized as Significant Patient Safety Issue
MedSun: Newsletter #17, September 2007

More than a year after the Joint Commission issued a Sentinel Event Alert about widespread occurrences of tubing and catheter misconnections—errors that can lead to potentially deadly consequences—much attention remains focused on this important patient safety issue.

Earlier this summer, the Wall Street Journal ran a story about the growing concern among the health care industry, Government agencies, and patient safety organizations about tubing misconnection errors. The article referenced the work being done by William Beaumont Hospital, a MedSun site, to address the problem. Beaumont’s work in this area was also presented at the March Conference for MedSun Representatives. A team of staff members made two presentations at the conference: “Tubing and Catheter Misconnections: The Beaumont Experience” and “MedSun-Sponsored Research on Misconnections Involving Medical Devices.” Slides from both presentations are included on the post-conference CD-ROM that was mailed to MedSun Representatives who attended.

The Wall Street Journal article can be accessed through its Web site by searching on “tube misconnections.”

Premier Safety Institute’s newsletter Safety Share also featured an article on the topic¸ “Tubing Misconnections—Better Technology Needed To Eliminate Risk,” in its July issue.

The June issue of MedSun News included a link to an article on luer connector and tubing misconnections written by FDA nurse consultants Beverly Gallauresi, Melissa Eakle, and Audrey Morrison.

To learn more about tubing misconnection error, see the next two articles in this newsletter edition.

Additional Information:

Wall Street Journal
http://online.wsj.com/public/us

Tubing Misconnections—Better Technology Needed To Eliminate Risk
http://www.premierinc.com/quality-safety/tools-services/safety/safety-share/07-07-full-txt.jsp#story-02

Safe Practices in Patient Care
http://www.safe-practices.org/


MedSun Newsletters are available at www.fda.gov/cdrh/medsun