The Joint Commission on Accreditation of Healthcare Organizations issued a Sentinel Event Alert that urges healthcare organizations to pay special attention to how tubes and catheters are connected to patients, and challenges 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 FDA, the Institute for Safe Medication Practices and U.S. Pharmacopoeia 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 a Sentinel Event Alert to more than 12,000 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 adapter.  Using a tube or catheter for something other than its intended purpose also may signal, or cause, a misconnection.

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