Eliminating tubing and catheter misconnections

JCAHO issued an alert last week urging health care organizations to pay special attention to how tubes and catheters are connected to patients.

Reports to the commission and other organizations show that tubing and catheter misconnection errors occur frequently and lead to fatalities.

Important warning signs of a possible misconnection include having to force-fit tubes together or having to use an adaptor.

To reduce the risk of errors relating to tube misconnections, JCAHO recommends that health care organizations:

* Avoid purchasing non-intravenous equipment with tubing connectors that permit connection with IV connectors
* Conduct tests on new tubing and catheters to identify potential for misconnections
* Always trace a tube or catheter from the patient to the point or origin before connecting a new device or infusion
* Route tubes and catheters having different purposes in different, standardized directions
* Emphasize the risk of tubing misconnections in clinician orientation and training programs