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Search results for "Device-related Complications"
- Administration Errors
- Device-related Complications
- Indwelling Tubes and Catheters
- Quality and Safety Professionals
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. August 20, 2014;(53):1-6.
The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Journal Article > Study
Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring.
Ligi I, Millet V, Sartor C, et al. Pediatrics. 2010;126:e1461-e1468.
This study adopted an anonymous monitoring system for iatrogenic events to drive prevention initiatives and necessary system changes.
Journal Article > Commentary
Guenter P, Hicks RW, Simmons D, et al. Jt Comm J Qual Patient Saf. 2008;34:285-292.
This article describes factors contributing to errors in enteral nutrition delivery and offers strategies to prevent medical tubing misconnections.
Journal Article > Study
An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program.
Hicks RW, Becker SC. J Infus Nurs. 2006;29:20-27.
The authors analyzed 5 years' worth of Medmarx data and found three trends in intravenous drug administration that predisposed patients to harm: product shortages, calculation errors, and tubing interconnectivity.