Blood Pressure Monitor Connected to IV in PACU
Misconnections are rare, but they can be dangerous and even fatal. In June 2012, Tricia Otstot’s healthy, active mother was brought to the PACU after a minor procedure for carpal tunnel done under local anesthetic. “We were informed by the surgeon and anesthesiologist that the PACU RN had hooked the blood pressure monitor into my mother’s IV, which caused an air embolism that killed her. I’m sharing her story because it somehow eases the pain to feel like some purpose can come out of the terrible error that took my mom.”
Stay Connected is a critically important safety initiative to educate people across the healthcare industry and make sure preventable tragedies—like what happened to Tricia’s mother—don’t happen in the future.
Coming October 1—The transition to safer connectors begins!
Introduction of transition sets in the US, Canada, Puerto Rico
Tell your colleagues
Did you know? piece-1
Tubing misconnections are widely recognized as being underreported, partly because of a lack of understanding of the reasons that cause misconnections and partly because of the negative culture surrounding error reporting. When unrelated devices are compatible, risks abound, including distractions, low lighting, multiple devices and lines, time pressures, disconnections, moving patient setting, and lack of tactile feedback.
Learn more about the risk of misconnections
Do you have? piece-2
The Stay Connected educational wristlet
Stop by and talk to a GEDSA representative at an upcoming event to get this educational wristlet with the new ENFit connector.
See where GEDSA will be next
Have you met?
Peggi Guenter, PhD, RN
Senior Director of Clinical Practice and Advocacy
American Society for Parenteral and Enteral Nutrition
Peggi oversees the development of standards, guidelines, and safe practices for nutrition support and advocacy efforts for professionals and patients. She served as lead author for The Joint Commission Journal on Quality and Patient Safety position paper on enteral misconnections published in 2008.
Have you told?
Make sure your Nursing, Nutrition and Dietetics leads are ready
Share this email and other Stay Connected tools and information with your nurse managers, nursing staff, and dietitians to help smooth the transition to the new ENFit connectors.
Forward this email to your colleagues
Where to Find Us
May 19—May 22 National Teaching Institute and Critical Care Exposition, Denver, CO
May 31—June 2 Association for the Advancement of Medical Instrumentation Conference & Expo, Philadelphia, PA
May 31—June 4 Medication Safety Collaborative, Las Vegas, NV
June 10—June 13 Premier Breakthroughs Conference & Exhibition, San Antonio, TX
June 23—June 27 Oley Foundation Annual Conference, Orlando, FL
The Stay Connected initiative is organized by the Global Enteral Device Supplier Association (GEDSA) in partnership with leading regulators, associations and other supporting organizations.
If this email was forwarded to you and you would like to sign up to Stay Connected, click here.
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