JCAHO Alert: Tubing misconnections—a persistent and potentially deadly occurrence

wow. very scary stuff.
if i have pts who are hooked up to sev'l different lines, i always label them. it does take extra time but you really can't afford not to.

leslie

Gosh- this may sound mean but you have to be just plain STUPID or BLIND to connect a NIBP cuff or SCD to an IV or tube feeding to a CBI and so on. I mean, you would have to be paying NO ATTENTION whatsoever. In that case, maybe these people shouldn't be in nursing.

I liked what the article had to say about prevention, though. Turn on a light, follow lines to point of origin, label things, etc. Oh yeah. And don't carry PO liquid meds to the bedside in a syringe even if you measured it in a syringe. There was a local case I heard of where someone put Milk of Mag in a central line doing that; gives me shivers to think of it. I've gotten pretty OCD about my central lines: I line up syringes on the counter for the drugs and put needles by them. Then I look at it and put flushes before each drug syringe, in between them and after, then another syringe with needle at the end for heparin flush. THEN label 'em as I draw 'em up. I never label the salines unless I think I'm not giving the drugs right then. But it can get downright complicated if you expect to push drugs then draw blood, then change one or all of the needleless valves... I'd hate to have been the nurse who said, ok while I'm at it let's give him some MOM and then boom. Dead patient, bybye license. It would have been well worth it to take some extra time to squirt the MoM into a paper cup.

Gosh- this may sound mean but you have to be just plain STUPID or BLIND to connect a NIBP cuff or SCD to an IV or tube feeding to a CBI and so on. I mean, you would have to be paying NO ATTENTION whatsoever. In that case, maybe these people shouldn't be in nursing.