News | July 04, 2006

Reports Show Misconnection Errors Occur Frequently, JCAHO Issues Sentinel Event Alert

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.

Related Content

PET/CT Changes Care for 59 Percent of Suspected Recurrent Prostate Cancer Cases
News | Prostate Cancer | June 13, 2018
A recently presented investigational clinical trial evaluated the impact of 18F fluciclovine positron emission...
Nuclear imaging scan showing very good tissue delineation. Scan performed on a Biograph Vision positron emission tomography/computed tomography (PET-CT) system from Siemens Healthineers.

Nuclear imaging scan showing very good tissue delineation. It offers crisp overall image quality and sharply delineates the muscle and fat planes, vertebral margins and end plates, billiary radicals, renal calyces, aortic wall and papillary muscles of the heart. Scan performed on a Biograph Vision positron emission tomography/computed tomography (PET-CT) system from Siemens Healthineers.

Technology | PET-CT | June 05, 2018
June 5, 2018 — The U.S.
Emerging Trends in Nuclear Medicine
Feature | Nuclear Imaging | June 04, 2018 | By Jeff Zagoudis
Nuclear imaging and its various modalities have long played an important role in the diagnosis and treatment of numer
PET Imaging Agent Could Provide Early Diagnosis of Rheumatoid Arthritis

Coronal 18F-FEDAC PET/CT section of a mouse with collagen-induced arthritis. (A) On day 23 and day 37, increased uptake is noted in the front and hind paws of this mouse with collagen-induced arthritis. (B) Predictive performance of day 23 18F-FEDAC uptake for the development of clinical arthritis. ROC = receiver operating characteristic; Sn = sensitivity; Sp = specificity. Credit: Seoul National University and Ewha Womans University, Seoul, South Korea

News | PET Imaging | May 17, 2018
A novel positron emission tomography (PET) tracer developed by Korean researchers can visualize joint inflammation and...
PET Imaging Shows Protein Clumping May Contribute to Heart Failure Development
News | PET Imaging | May 11, 2018
A team led by Johns Hopkins University Researchers has discovered that protein clumps appear to accumulate in the...
News | Radiopharmaceuticals and Tracers | May 09, 2018
Blue Earth Diagnostics signed an exclusive, worldwide agreement with Scintomics GmbH, Germany, a specialist in...
Novel PET Agent Could Help Guide Therapy for Brain Diseases

Rat brain 11C‐Me‐NB1 PET images (0‐60 min) superimposed on an MRI template. Credit: SD Krämer et al., ETH Zurich, Zurich, Switzerland

News | PET Imaging | April 10, 2018
Researchers have developed a new imaging agent that could help guide and assess treatments for people with various...
The Chalk River nuclear reactor license has been renewed, but will be decommissioned by 2028.

The Chalk River nuclear isotope reactor license has been renewed, but will be decommissioned by 2028. The reactor supplies about 50 percent of the world's supply of Tc99m.

Feature | Nuclear Imaging | April 02, 2018 | Dave Fornell
April 2, 2018 – The Canadian Nuclear Safety Commission (CNSC) announced March 29 that it renewed Canadian Nuclear Lab
The yellow in the anterolateral entorhinal cortex of the young brain indicates significant activity, something that is absent in the older brain.

This figure shows two different brains that are aligned to a common template space for comparison. The yellow in the anterolateral entorhinal cortex of the young brain indicates significant activity, something that is absent in the older brain. CREDIT: Zachariah Reagh

News | Nuclear Imaging | March 08, 2018
As we get older, it's not uncommon to experience "senior moments," in which we forget where we parked our car or call...
Overlay Init