Caution: tubing misconnections can be deadly.
Caution: tubing misconnections can be deadly.
复制标题
注意：管道连接错误可能会致命。
DOI：
10.1016/s0001-2092(07)60133-1
复制
发表时间：
2007
期刊：
影响因子：
0.9
通讯作者：
Hicks,RodneyW
中科院分区：
文献类型：
--
作者：
Beyea,SuzanneC;Simmons,Debora;Hicks,RodneyW
2006年4月，联合委员会发布了关于油管连接错误风险的哨兵事件警报。(1)本警报描述了由于管道连接错误导致一名患者永久性丧失功能和八名患者死亡的情况。每个围手术期临床医生都应该意识到并学习如何避免这种常见的潜在致命错误。当护士或其他临床医生无意中将管子或导管的一端连接到错误的管子或设备时，就会发生管道连接错误。例如，一种常见的错误连接发生在卫生保健小组成员将肠饲管的男性端连接到静脉注射导管或腹膜透析导管时。也可以将血压注入管连接到静脉导管上。(1）
In April 2006, The Joint Commission issued a Sentinel Event Alert pertaining to the risk of tubing misconnections.(1) This alert describes injury to one patient who suffered permanent loss of function and the deaths of eight patients as the result of tubing misconnections. Every perioperative clinician should be aware of and learn how to avoid this common and potentially deadly error.A tubing misconnection occurs when a nurse or other clinician unintentionally connects one end of a tube or catheter to the wrong tube or device. For example, one common misconnection occurs when a member of the health care team connects the male end of an enteric feeding tube to an IV catheter or a peritoneal dialysis catheter. It also is possible for a blood pressure insufflator tube to be connected to an IV catheter.(1)