Joint Commission Warns of Tube Misconnection Risk

Recently the Joint Commission issued an alert containing updated recommendations and strategies to prevent tubing misconnections as the health care field transitions to new manufacturing standards for medical tubing connectors. Developed by the International Organization for Standards, the new standards are expected to make tubing misconnections nearly impossible, but old connectors will remain in the market until they are sold out, leading to potential confusion, according to the Sentinel Event Alert.

Example of a Luer lock and a Luer slip.

Luer Lock (left) and Luer Slip (right) Photo Courtesy of Beaumont Hospitals

The Joint Commission urges hospitals, long-term care facilities, home health providers and others that use medical tubing to begin planning for the October transition to the new connectors and remain alert for possible misconnections. “Tubing misconnections are the root cause of too many episodes of patient harm, and The Joint Commission is committed to helping health care organizations prevent them,” said Mark Chassin, M.D., Joint Commission president and CEO. “Organizational leadership is the first line of defense in this transition to the new connectors. Leaders must assume the responsibility for ensuring the safe adoption of the new standards and they must empower their employees to not be afraid to speak up if they discover a problem.”

Because these connectors are compatible between different delivery systems, patient injuries and deaths have occurred when medicines, liquid feeding formulas, or air were accidentally delivered through the wrong tubing. These errors are sometimes called tubing misconnections, wrong route errors, catheter misconnections or Luer misconnections. It is vitally important that all health care clinicians receive appropriate orientation and training that emphasizes the risk of tubing misconnections. This includes not only acute care settings, but, long-term care, rehabilitation facilities, home health care, physician offices, and any non-clinical settings in which a small-bore connector may be used on a patient.

The FDA has been aware of the problem for years, and has information on it’s website that explains:

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, and gave other examples of adverse effects nationwide. According to the Joint Commission’s alert, 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 under reported; 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. The risk for tubing misconnection is high, considering that almost all patients admitted to the hospital are likely to receive an IV.  This risk is also seen in other settings.

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