Sentinel Event Alert #36: The Story and Investigation behind Tubing Misconnections

2.50
Hdl Handle:
http://hdl.handle.net/10755/147516
Type:
Presentation
Title:
Sentinel Event Alert #36: The Story and Investigation behind Tubing Misconnections
Abstract:
Sentinel Event Alert #36: The Story and Investigation behind Tubing Misconnections
Conference Sponsor:Sigma Theta Tau International
Conference Year:2007
Author:Simmons, Debora, RN, MSN, CCRN, CCNS
P.I. Institution Name:The University of Texas M D Anderson Cancer Center
Title:Senior Clinical Quality Analyst
Co-Authors:Krisanne Graves, RN, BSN, CPHQ
[Clinical session research presentation] Tubing misconnections have been prevalent in the healthcare industry for over 30 years - the causative factors are rooted in human factors science and will require a design change in order to prevent what is a fatal error in many cases. The authors are the event analysts for the first non punitive error reporting pilot for nurses in partnership with a regulatory board in the United States, the Healthcare Alliance Safety Partnership or HASP (www.texashasp.org). During the course of an event investigation, it was found that a major design flaw was responsible for the inadvertent infusion of a feeding into an IV line. The resulting analysis revealed a 35 year history of similar errors in relevant medical literature, several FDA alerts and the formation of several work groups for setting industry standards.   Analysts will describe the history and commonalities of this medical error, the dramatic affects that it can have on the patient and the provider, the current state of the regulatory environment in relation to this issue, and interventions that can be taken by healthcare institutions to limit the possibility of a like medical error occurring in their facility before national standards are mandated.  During the presentation the tools utilized in the analysis process including Cause MappingTM, a visual representation of contributing factors and the Eindhoven Classification (modified for healthcare) will be discussed and demonstrated.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleSentinel Event Alert #36: The Story and Investigation behind Tubing Misconnectionsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/147516-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Sentinel Event Alert #36: The Story and Investigation behind Tubing Misconnections</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Simmons, Debora, RN, MSN, CCRN, CCNS</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">The University of Texas M D Anderson Cancer Center</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Senior Clinical Quality Analyst</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">Dsimmon@mdanderson.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Krisanne Graves, RN, BSN, CPHQ</td></tr><tr><td colspan="2" class="item-abstract">[Clinical session research presentation] Tubing misconnections have been prevalent in the healthcare industry for over 30 years - the causative factors are rooted in human factors science and will require a design change in order to prevent what is a fatal error in many cases. The authors are the event analysts for the first non punitive error reporting pilot for nurses in partnership with a regulatory board in the United States, the Healthcare Alliance Safety Partnership or HASP (www.texashasp.org). During the course of an event investigation, it was found that a major design flaw was responsible for the inadvertent infusion of a feeding into an IV line. The resulting analysis revealed a 35 year history of similar errors in relevant medical literature, several FDA alerts and the formation of several work groups for setting industry standards. &nbsp; Analysts will describe the history and commonalities of this medical error, the dramatic affects that it can have on the patient and the provider, the current state of the regulatory environment in relation to this issue, and interventions that can be taken by healthcare institutions to limit the possibility of a like medical error occurring in their facility before national standards are mandated. &nbsp;During the presentation the tools utilized in the analysis process including Cause MappingTM, a visual representation of contributing factors and the Eindhoven Classification (modified for healthcare) will be discussed and demonstrated.</td></tr></table>en_GB
dc.date.available2011-10-26T09:33:13Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T09:33:13Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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