Follow us on Twitter Friend us on Facebook Look for us on Google Plus Share with your Friends Print this Page
Sunday 2:07 CST, May 24, 2015

Topic Details


Topic Library Item

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

April 3, 2006


Editorial note: As of August 20, 2014, please use the updated information and guidance on this topic that is in Sentinel Event Alert Issue 53, "Managing risk during transition to new ISO tubing connector standards."

sea 36 tubing

Tubing 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.