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The Joint Commission on Accreditation of Healthcare Organizations issued Sentinel Event Alert in April 2006 urging healthcare organizations to pay special attention to how tubes and catheters are connected to patients and challenging the manufacturers of these devices to redesign them in ways that will make dangerous misconnections much less possible.


Reports to the Joint Commission, ECRI, the Food and Drug Administration, the Institute for Safe Medication Practices, and United States Pharmacopeia show that tubing and catheter misconnection errors occur frequently and lead to deadly consequences in many instances. This reality prompted the Joint Commission to issue Sentinel Event Alert to more than 12000 healthcare organizations nationwide, including hospitals, ambulatory care centers, home care agencies, nursing homes, and behavioral healthcare facilities, to create new awareness of the problem and offer practical solutions to avoiding these occurrences.


Important warning signs of a possible misconnection, according to the Alert, include having to force fit tubes together or having to use an adaptor. Using a tube or catheter for something other than its intended purpose may also signal, or cause, a misconnection. To reduce the risk of errors related to tubing misconnections, the Joint Commission's Sentinel Event Alert newsletter recommends that healthcare organizations take the following specific steps:


* Avoid purchasing nonintravenous equipment with tubing connectors that permit connection with intravenous connectors.


* Conduct tests on and assess risks of new tubing and catheter purchases to identify the potential for misconnections and take appropriate preventive measures before using them.


* Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.


* Route tubes and catheters have different purposes in different, standardized directions; for example, intravenous lines are routed toward the head, whereas enteric lines are routed toward the feet.


* Recheck connections and trace all patient tubes and catheters to their sources as a standard of care when a patient arrives in a new care setting.


* Emphasize the risk of tubing misconnections in clinician orientation and training programs.


* Inform patients and their families of the importance of getting help from nurses or doctors whenever there is a real or perceived need to connect or disconnect devices or infusions.



The warning about tubing misconnections is one of a continuing series of Sentinel Event Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts are drawn from one of the nation's most comprehensive voluntary reporting systems for serious adverse events in healthcare. The Sentinel Event Database includes detailed information on both the adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, healthcare-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission Web site at