TJC Warns Hospitals of Deadly Medical Tubing Mistakes
5. Trace tubing or catheters from the patient to the point of origin before connecting or reconnecting, at any transition, and as part of the hand-off process.
6. Route tubes and catheters having different purposes in different, standardized directions, especially in neonates.
7. Use labels. When there are different access sites or several bags are hanging, tubing should be labeled to reduce chance of misconnection, especially when multiple IV lines are in use.
8. Ensure implementation of safe practices for administration of high-alert meds. For high-risk medications delivered via an epidural, intrathecal, or arterial route, label the catheter and do not use tubing or catheters that have injection ports.
9. Use tubing and related equipment only as intended.
10. Take inventory and store carefully. Package all parts needed for initial enteral feeding together to minimize the chance of using dissimilar tubes or catheters.
11. Educate the staff appropriately.
12. Make sure non-clinical staff, patients and visitors that they must get help from clinicians whenever there is a real or perceived need to connect or disconnect devices or infusions. They should not attempt to disconnect or connect these devices themselves.
13. Identify and improve unsafe working conditions, especially fatigue, inadequate staffing, and interruptions.
Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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