Preventing catheter/tubing misconnections: much needed help is on the way.

Newspaper/Magazine Article

Preventing catheter/tubing misconnections: much needed help is on the way.

August 4, 2010

ISMP Medication Safety Alert! Acute care edition! July 15, 2010;15:1-2.

This piece describes reports of tubing misconnections and discusses upcoming standards for connectors that will prevent such errors.

Free full text

Related Resources From the Same Author(s)

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Survey shows recession has weakened patient safety net.

January 27, 2010

Drug shortages threaten patient safety.

August 11, 2010

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

Assessing medication safety in settings not designated solely for pediatric patients.

June 28, 2023

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Small effort, big payoff...automated maximum dose alerts with hard stops.

October 2, 2013

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

August 11, 2021

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

August 12, 2020

FentaNYL patch fatalities linked to "bystander apathy." We ALL have a role in prevention!

August 21, 2013

Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.

September 7, 2022

IV push medications survey results—part 1 and part 2.

November 28, 2018

Safety requires a state of mindfulness.

March 22, 2006

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.

August 10, 2016

Correct use of inhalers: help patients breathe easier.

July 27, 2016

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.

July 25, 2018

Students have a key role in a culture of safety: analysis of student-associated medication incidents.

August 8, 2018

With oral chemotherapy, we simply must do better!

July 30, 2014

Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.

July 16, 2014

Use of tall man letters is gaining wide acceptance.

August 13, 2008

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Epidural-IV route mix-ups: reducing the risk of deadly errors.

July 16, 2008

High-reliability organizations (HROs): what they know that we don't (Part II).

August 24, 2005

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

Medication orders with future start dates: how far away is too far?

July 27, 2022

Administration of concentrated potassium chloride for injection during a code: still deadly!

June 30, 2021

Results of survey on pediatric medication safety—part 1 and part 2.

June 17, 2015

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

A mislabeling event with batched drugs: the unintended consequences of practice changes.

February 19, 2014

November 14, 2007

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

July 14, 2021

Patient death tied to lack of proper escalation process for barcode scanning failures.

October 4, 2023

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Building a case for medication reconciliation.

May 3, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Your attention please... designing effective warnings.

September 6, 2006

Rapid response team activation by patients can mitigate errors.

June 21, 2006

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Please don't sleep through this wake-up call.

March 27, 2005

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Preventing medication errors during codes.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 29, 2011

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

That’s the way we do things around here!

March 9, 2011

How has the current economy affected patient safety?

September 23, 2009

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Is an indication-based prescribing system in our future?

November 30, 2016

Understanding human over-reliance on technology.

September 28, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

Related Resources

A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.

July 5, 2023

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

June 28, 2023

Evaluation of detected medication errors within the operating room at an academic medical center.

June 21, 2023

Smart infusion pump investigations after an unexplained over-infusion.

May 31, 2023

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update.

May 17, 2023

Medical line entanglement: the unspoken patient safety hazard of medical devices.

May 3, 2023

More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA.

May 3, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.

April 5, 2023

Home medical device safety tops ECRI'S list of healthcare technology.

February 15, 2023

Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls.

January 25, 2023

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long?

November 9, 2022

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

Rethinking use of air-safety principles to reduce fatal hospital errors.

September 7, 2022

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

March 30, 2022

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

February 24, 2022 - February 24, 2022

Racial bias in pulse oximetry measurement.

December 20, 2020

Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study.

September 25, 2019

Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.

September 18, 2019

Patient safety incidents caused by poor quality surgical instruments.

September 4, 2019

FDA to end program that hid millions of reports on faulty medical devices.

May 29, 2019

Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.

May 29, 2019

Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?

April 24, 2019

The computerized ECG: friend and foe.

April 10, 2019

Unintended patient safety risks due to wireless smart infusion pump library update delays.

March 13, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

See More About The Topic

Health Care Providers

Risk Managers

Quality and Safety Professionals

Engineers

Administration Errors

Preventing catheter/tubing misconnections: much needed help is on the way.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Preventing catheter/tubing misconnections: much needed help is on the way.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site