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Sentinel Event Alert, Issue 36: Tubing misconnections—a persistent and potentially deadly occurrence

April 3, 2006

sea 36 tubingTubing and catheter misconnection errors are an important and under-reported problem in health care organizations. In addition, these errors are often caught and corrected before any injury to the patient occurs. Given the reality of and potential for life threatening consequences, increased awareness and analysis of these errors—including averted errors—can lead to dramatic improvement in patient safety.



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