Tubing misconnections--a systems failure with human factors: lessons for nursing practice.
In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.
Simmons
Debora
D
Texas A&M Health Science Center, Rural Community Health Institute, College Station, TX, USA.
Graves
Krisanne
K
D015984:Causality; D004750:Enteral Nutrition / Q000295:instrumentation / Q000451:nursing; D004868:Equipment Failure; D006804:Ergonomics; D005544:Forecasting; D006801:Humans; D007262:Infusions, Intravenous / Q000295:instrumentation / Q000451:nursing; D019300:Medical Errors / Q000145:classification / Q000379:methods / Q000451:nursing / Q000517:prevention & control; D015969:National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; D017283:Neonatal Nursing; D024802:Nurse's Role; D009741:Nursing Staff, Hospital; D017751:Safety Management / Q000458:organization & administration*; D013597:Systems Analysis; D017749:Total Quality Management / Q000458:organization & administration; D014481:United States