JCAHO issues sentinel alert on tubing misconnections
Ambulatory Safety Monitor, April 13, 2006
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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued a sentinel event alert that urges hospitals, ambulatory care centers, and other healthcare organizations to pay special attention to how tubes and catheters are connected to patients.
The sentinel event alert includes information on common types of misconnections as well as JCAHO recommendations for reducing errors. Among other suggestions, JCAHO recommends labeling and color-coding all tubes and catheters.
The JCAHO alert also calls on manufacturers of these devices to redesign tubing and connectors to reduce interoperability between disparate lines. Nine cases of tube misconnections have been reported to the Sentinel Event Database, eight of which resulted in a patient's death.
Click here to read the alert.
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