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Sentinel Event Alert 53 Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected.

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Presentation on theme: "Sentinel Event Alert 53 Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected."— Presentation transcript:

1 Sentinel Event Alert 53 Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using luer connectors, or connections can be “rigged” (constructed) using adapters, tubing or catheters. This is why new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers.

2 Managing risk of tubing misconnections during the transition to new ISO connector standards

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7 Managing risk of tubing misconnections during while we are waiting for the transition to new ISO connector standards

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10 © The Joint Commission, Reprinted with permission.

11 As we move toward the tubing/connector standardization we must remain alert to issues we see. When an issue is identified please report as a PSN and it will be reviewed by safety and purchasing for resolution and information sharing to mitigate potential problems.

12 See FAQs at stayconnected2014.org Other questions can be addressed to: Ashley Selby - Carey Smith - Donna Ianke - Sue Scott -


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