Tube Misconnection Errors Noted in WSJ
A recent report in the Wall Street Journal discussed a safety consideration in healthcare settings that may be overlooked: tube misconnections. While this event is most certainly a noteworthy medical error, incidence rates are unknown because of limited reporting. Nevertheless, the Joint Commission acknowledge the dramatic implications of such on patient safety.
The underlying cause of this mistake is a universal connection device, Luer fittings. The tool can be used to connect tubing for a wide array of devices used to deliver therapies which employ catheter use, such as central lines or epidurals.
The FDA has even stepped in and acknowledged the problem as a serious public health concern. They requested support for development of educational materials from the Beaumont Technology Usability Center.
Another organization, a purchasing alliance of over 1,500 hospitals named Premium, is creating educational materials for hospital staff members. Premier is also supporting initiatives by medical device manufacturers to eliminate similarities in tube connector designs.
Related story: Joint Commission Releases Guide
June 29, 2007 Related topics: Standards