Error-Avoidance Recommendations for Tubing Misconnections When Using Luer-Tip Connectors: A Statement by the USP Safe Medication Use Expert Committee

被引：10

作者：

Simmons, Debora ^{[1
]}

Phillips, Marjorie Shaw ^{[2
,3
,4
]}

Grissinger, Matthew ^{[5
,6
]}

Becker, Shawn C. ^{[7
]}

机构：

[1] Univ Texas MD Anderson Canc Ctr, Inst Healthcare Excellence, Houston, TX 77030 USA

[2] Med Coll Georgia MCG Hlth, Augusta, GA USA

[3] Georgia War Vet Nursing Home, Augusta, GA USA

[4] Univ Georgia, Coll Pharm, Athens, GA 30602 USA

[5] Inst Safe Medicat Practices, Error Reporting Programs, Huntingdon Valley, PA USA

[6] Penn Patient Safety Reporting Syst, Harrisburg, PA USA

[7] US Pharmacopeia, Ctr Adv Patient Safety, Patient Safety Initiat, Rockville, MD 20852 USA

来源：

JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY | 2008年 / 34卷 / 05期

关键词：

D O I：

10.1016/S1553-7250(08)34036-7

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

引用

页码：293 / 296

页数：4

共 13 条

[1]

Association of the Advancement of Medical Instrumentation, 1996, ENT FEED SET AD CONN

[2] Not again! Preventing errors lies in redesign - not exhortation [J].

Berwick, DM .

BMJ-BRITISH MEDICAL JOURNAL, 2001, 322 (7281) :247-248

[3]

Cohen Michael, 2008, COMMUNICATION 0220

[4] Enteral Feeding Misconnections: A Consortium Position Statement [J].

Guenter, Peggi ;

Hicks, Rodney W. ;

Simmons, Debora ;

Crowley, Jay ;

Joseph, Stephanie ;

Croteau, Richard ;

Gosnell, Cathie ;

Pratt, Nancy G. ;

Vanderveen, Timothy W. .

JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY, 2008, 34 (05) :285-292

[5]

Institute of Medicine, 1999, ERR IS HUMAN BUILDIN

[6]

Joint Commission on Accreditation of Healthcare Organizations USA, 2006, Sentinel Event Alert, P1

[7] Inadvertent attachment of a blood pressure device to a needleless IV "Y-site": Surprising, fatal connections [J].

Paparella, S .

JOURNAL OF EMERGENCY NURSING, 2005, 31 (02) :180-182

[8] Beyond the organisational accident: the need for "error wisdom" on the frontline [J].

Reason, J .

QUALITY & SAFETY IN HEALTH CARE, 2004, 13 :28-33

[9]

Reason J. T., 1990, HUMAN ERROR, DOI [DOI 10.1017/CBO9781139062367, 10.1017/cbo9781139062367]

[10]

Simmons D., LUER TIP SMALL BORE

← 1 2 →