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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.
Legislation/Regulation > Organizational Policy/Guidelines
ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
These guidelines explain how to examine equipment prior to administering anesthesia; the protocol includes checklists that can be used for specific equipment systems.
Sentinel Event Alert. April 3, 2006;(36):1-3.
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.