Tubing misconnections—a persistent and potentially deadly occurrence.

USA Joint Commission on Accreditation of Healthcare Organizations

Newspaper/Magazine Article

Tubing misconnections—a persistent and potentially deadly occurrence.

April 12, 2006

Organizations USAJC on A of H. Sentinel event alert. 2006;(36):1-3.

View more articles from the same authors.

This alert summarizes types of tubing misconnections reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and recommends 10 strategies to prevent their occurrence.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

December 5, 2018

Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.

January 22, 2014

Strategies to prevent healthcare-associated infections through hand hygiene.

July 30, 2014

Guidelines for the prevention of intravascular catheter-related infections.

May 25, 2011

Multistate point-prevalence survey of health care-associated infections.

April 9, 2014

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Smart infusion pump investigations after an unexplained over-infusion.

May 31, 2023

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

November 13, 2019

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

May 8, 2019

WebM&M Cases

One Bronchoscopy, Two Errors

January 1, 2019

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

August 17, 2016

Sleep and circadian misalignment for the hospitalist: a review.

August 3, 2016

July 27, 2016

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

July 13, 2016

The forgotten tourniquet—an update.

March 13, 2016

Alarm management: first things first: using reliable data to eliminate unnecessary alarms.

December 10, 2014

Managing risk during transition to new ISO tubing connector standards.

August 27, 2014

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

May 7, 2014

Cognitive and system factors contributing to diagnostic errors in radiology.

October 9, 2013

ACR guidance document on MR safe practices: 2013.

March 21, 2013

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.

September 26, 2012

Safe use of opioids in hospitals.

August 15, 2012

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

March 14, 2012

Radiation risks of diagnostic imaging and fluoroscopy.

August 31, 2011

ALERT: reports of severe harm after intravenous administration of breast milk to infants.

August 24, 2011

Inappropriate trust in technology: implications for critical care nurses.

March 30, 2011

Radiation offers new cures, and ways to do harm.

February 3, 2010

Preventing errors relating to commonly used anticoagulants.

October 1, 2008

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

August 27, 2008

2008 Recommendations for Pre-Anesthesia Checkout Procedures.

July 30, 2008

Improving heparin safety: a multidisciplinary invited conference.

July 23, 2008

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

July 16, 2008

WebM&M Cases

Wrong Route for Nutrients

July 1, 2008

See More About The Topic

Clinical Technologists

Physicians

Nurses

Health Care Executives and Administrators

Practice Guidelines

Tubing misconnections—a persistent and potentially deadly occurrence.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Tubing misconnections—a persistent and potentially deadly occurrence.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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