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Preventing misconnections of lines and cables.

The hospital environment is filled with lines and cables connecting medical devices with patients. With so many connections to be made, it's not surprising that, occasionally, one of them will be incorrect. Often, such mistakes are caught before harm is done. But when they aren't, patients can be harmed or even killed. There are two basic ways in which hospitals can reduce the likelihood of misconnections, and they should be applied together. First, whenever possible, hospitals should purchase equipment whose design makes a misconnection unlikely or prompts users to make the correct connection. Second, hospitals should implement general policies and specific work practices that keep misconnections to a minimum. In concert with these efforts, hospitals should conduct a risk assessment to identify specific misconnection hazards within the facility. This article describes the specific steps hospitals should take to tackle misconnections. It also pinpoints the more important misconnection scenarios to look for during a risk assessment. And it includes a checklist that will facilitate not only the risk assessment but also the overall misconnection-prevention endeavor.