Joint Commission warns of tubing misconnections


The Joint Commission has issued a Sentinel event alert regarding tubing misconnections, which continue to cause severe patient injury and death.

Tubes with different functions can easily be connected using luer connectors, or connections can be “rigged” (constructed) using adapters, tubing or catheters.

“This is why new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers,” said the Joint Commission in its alert.

“Through an international consensus process, the standards are being developed, tested and approved to assure reliable designs and processes.”

The phased implementation of redesigned tubing connectors that are the result of these new ISO connector standards begins now.

“The Joint Commission urges health care organizations to be vigilant and begin planning for the upcoming period of transition, which will introduce changes and new risks into the health care environment,” warned the Joint Commissions.

Under the new ISO connector standards, small-bore (less than 8.5 mm inner diameter) connectors will be engineered to make it nearly impossible to connect one delivery system to another delivery system that serves a completely different function – for example, accidentally connecting a feeding administration set to a tracheostomy tube, or an intravenous (IV) tube to an epidural site.

The first new ISO connector standard (ANSI/AAMI/ISO 80369-1) has been adopted and others are expected to be introduced and adopted through 2014 and 2015.

“Health care organizations should begin preparing for changes in connectors and do everything possible during the transitional period to avoid tubing misconnections,” said the Joint Commission. “The benefit of the transition is that, ultimately, the engineered solutions will make systems safer for all patients.”

The New York Times reported on the death of a fetus and expectant mother after a feeding tube was accidentally connected into the mother’s bloodstream. In 34 various publications, 116 other case studies were found involving misconnections directing enteral feeding solutions into IV lines. These adverse events resulted in 21 deaths.

“It is believed that tubing misconnections are underreported; adverse events related to tubing misconnections are sometimes not reported, especially when the mistake does not result in harm to the patient, and they are sometimes reported under another category, such as a medication error,” stated the Joint Commission.

Joint Commission, Sentinel Event Alert, US,