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

GE Healthcare Recalls Millennium Nuclear Medicine Systems
News | Nuclear Imaging | November 15, 2018
GE Healthcare announced it is recalling its Millennium Nuclear Medicine Systems due to an incident in which the the top...
Artificial Intelligence Predicts Alzheimer's Years Before Diagnosis
News | Neuro Imaging | November 14, 2018
Artificial intelligence (AI) technology improves the ability of brain imaging to predict Alzheimer’s disease, according...
Researchers Awarded 2018 Canon Medical Systems USA/RSNA Research Grants
News | Radiology Imaging | November 13, 2018
The Radiological Society of North America (RSNA) Research & Education (R&E) Foundation recently announced the...
Subtle Medical Showcases Artificial Intelligence for PET, MRI Scans at RSNA 2018
News | Artificial Intelligence | November 13, 2018
At the 2018 Radiological Society of North America annual meeting (RSNA 2018), Nov. 25-30 in Chicago, Subtle Medical...
University of Missouri Research Reactor First U.S. I-131 Supplier in 30 Years

MURR is the only supplier of I 131 in the United States and the first U.S. supplier since the 1980s. Image courtesy of University of Missouri

News | Radiopharmaceuticals and Tracers | November 13, 2018
The University of Missouri Research Reactor (MURR) recently shipped its first batch of Iodine-131 (I-131), a...
MEDraysintell Projects Increasing Mergers and Acquisitions in Nuclear Medicine
News | Nuclear Imaging | November 07, 2018
With the recent announcement by Novartis to acquire Endocyte , interest from the conventional pharmaceutical industry...
A PET/CT head and neck cancer scan.

A PET/CT head and neck cancer scan.

Feature | Nuclear Imaging | November 05, 2018 | By Sabyasachi Ghosh
“Experimental validation implemented in real-life situations and not theoretical claims exaggerating small advantages
PET Imaging Offers New Possibilities in Chronic Liver Disease Management

Hepatic 18F-FDG, 18F-FAC, and 18F-DFA accumulation are affected in a mouse model of autoimmune hepatitis. (A) Histochemical and immunohistochemical analyses of liver sections from vehicle- and ConA-treated mice. Scale bars represent 50 microns. Transverse PET/CT images (B) and quantification (C) of vehicle- and ConA-treated mice injected with 18F-FDG, 18F-FAC, and 18FDFA. Livers are outlined in a white dotted line. Quantification represents radiotracer accumulation in the liver normalized to a background organ. Image courtesy of Salas J.R., Chen B.Y., Wong A., et al.

News | PET Imaging | October 24, 2018
While liver biopsies are powerful and reliable, they are also invasive, painful, limited and subject to complications....
CORAR Supports Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2018
News | Radiopharmaceuticals and Tracers | October 12, 2018
October 12, 2018 — The Council on Radionuclides and Radiopharmaceuticals Inc.
Huntsman Cancer Institute Installs First Preclinical nanoScan 3T PET/MRI in U.S.
News | PET-MRI | October 10, 2018
The Center for Quantitative Cancer Imaging at Huntsman Cancer Institute (HCI) at the University of Utah in Salt Lake...