Executive Summary

Beaumont Commercialization Center (Royal Oak, MI) was named a finalist for the 3rd Health Devices Achievement Award in September 2008 for its program designed to help reduce tubing misconnections.

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Beaumont Commercialization Center (Royal Oak, MI) wanted to address the problem of tubing misconnections. A persistent concern in hospitals, misconnections have been the subject of considerable attention, including a 2006 Joint Commission Sentinel Event Alert.

After conducting an extensive literature review to understand the issues, Beaumont employees created a multidisciplinary task force to identify all possible misconnection hazards, starting in its pediatric intensive care unit. This arduous process involved collecting every piece of equipment in the unit, creating a database classifying all the connectors, and photographing each connector. The team members then developed human factors testing protocols and examined the connectors one by one to identify potential misconnections and their severity, as well as to assess the physical feel of the connections.

Another key part of the plan was education and training. The task force developed posters for various areas of the hospitals. They also devised a "learn by doing" approach to staff education. Using a stuffed monkey to which various tubes were attached, they allowed employees to use—and deliberately misuse—various connector types so they could experience the right and wrong way to make connections.

Out of this process came a corporate Misconnection Prevention Policy covering equipment purchases, technical and safety testing, risk assessment, guidelines for clinical staff, and orientation and education.

The result? Beaumont reported that their misconnection rate had dropped to zero.

Since completing this phase of the project, Beaumont has expanded its scope to include other facilities in the Beaumont Hospitals system. And research will continue, including work that will be done under a contract with the U.S. Food and Drug Administration.

This project earned Beaumont Commercialization Center recognition as a finalist for the 3rd Health Devices Achievement Award, issued by ECRI Institute in 2008 to honor excellence in health technology management. Learn about the other submissions that achieved recognition.




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Accidents; Quality Assurance/Risk Management


Ambulatory Care Center; Ambulatory Surgery Center; Assisted-living Facility; Behavioral Health Facility; Dialysis Facility; Emergency Department; Endoscopy Facility; Home Care; Hospice; Hospital Inpatient; Hospital Outpatient; Imaging Center; Independent Living Facility; Physician Practice; Rehabilitation Facility; Short-stay Facility; Skilled-nursing Facility; Substance Abuse Treatment Facility; Trauma Center

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Allied Health Personnel; Nurse; Patient Safety Officer; Risk Manager

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