SEA.300 According to The Joint Commission, tubing misconnections cause harm to way too many patients; so, the agency has issued a Sentinel Event Alert aiming to reduce occurrences of error as hospitals transition over to a new type of tubing connector in October 2014.  New standards for the use of these connectors are being developed as well through a collaboration of the International Organization for Standardization (ISO), the Association for the Advancement of Medical Instrumentation (AAMI), clinicians, manufacturers and regulators, including the U.S. Food and Drug Administration (FDA).

TJC acknowledges that the risk is naturally high because nearly all patients admitted to hospitals and other healthcare facilities receive intravenous infusions. A New York Times article detailed one devastating event in which the mishandling of tubing led to the death of a fetus and mother because a feeding tube was accidentally introduced into the mother’s bloodstream. Such misconnections happen because tubes with different functions can easily be connected using  luer connectors and even poorly constructed adapters of sorts. The new connectors will make it nearly impossible to connect tubing delivery systems that serve different functions.

Ultimately, the new tubing systems will be safer for all patients, but until that transition is complete and old tubing supplies are depleted,  TJC is urging healthcare organizations to be especially vigilant in their approach to such protocols.

In its alert, TJC offers several strategies to help prepare for the new connector standards. Recommended strategies include: assessing and managing current risks for injury; assessing and adapting existing systems, processes, and protocols to carefully transition to the new connectors; effective processes and procedures for prevention of misconnections; and implementation of safe practices for the administration of high-alert medications.

To read TJC’s Sentinel Event Alert: Managing risk during transition to new ISO tubing connector standardsclick here.