Inadvertent attachment of a blood pressure device to a needleless IV "Y-site": surprising, fatal connections.
Paparella
Susan
S
Institute for Safe Medication Practices, Huntingdon Valley, PA, USA. ismpinfo@ismp.org
D015924:Blood Pressure Monitors / Q000009:adverse effects*; D002408:Catheters, Indwelling / Q000009:adverse effects*; D004618:Embolism, Air / Q000209:etiology* / Q000401:mortality; D016529:Emergency Nursing; D004868:Equipment Failure; D006804:Ergonomics; D017809:Fatal Outcome; D006801:Humans; D007262:Infusions, Intravenous / Q000295:instrumentation* / Q000451:nursing; D019300:Medical Errors / Q000009:adverse effects* / Q000401:mortality / Q000451:nursing; D024802:Nurse's Role; D032024:Personnel Delegation; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D014486:United States Food and Drug Administration