Using HFMEA to assess potential for patient harm from tubing misconnections.

Background: Reported cases of tubing misconnections and other tubing errors prompted Columbus Children's Hospital to study their potential for harm in its patient population. A Health Failure Mode and Effects Analysis (HFMEA) was conducted in October 2004 to determine the risks inherent in the use and labeling of various enteral, parenteral, and other tubing types in patient care and the potential for patient harm.

Methods: An assessment of the practice culture revealed considerable variability among nurses and respiratory therapists within and between units.