JCAHO warns about problems with some tubing

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued a special warning to double-check how tubes and catheters are connected to patients, citing a number of dangerous misconnections.

Reports to the Joint Commission and other groups show that tubing and catheter misconnection errors occur frequently and lead to deadly consequences in many instances. In response, the Joint Commission issued a Sentinel Event Alert nationwide to create new awareness of the problem and offer practical solutions to avoiding these occurrences.

Many tubing misconnections are caught before the patient is injured, the Joint Commission reports, but the errors still pose a real threat to patient safety. The problem can be overcome through heightened vigilance and a systematic approach to avoiding misconnections, the Joint Commission says.

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. To reduce the risk of errors related to tubing misconnections, the Joint Commission recommends that health care organizations take these 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.
  • 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 having different purposes in different, standardized directions. For instance, IV lines are routed toward the head, and 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.