In hospitals and other healthcare settings, including long-term care, a misconnected tube can cause severe resident injury and/or death. This error may occur because tubes with different functions can easily be connected using Luer connectors, or connections can be “rigged” using adapters, tubing or catheters.
Medications and other therapies may be delivered using luer, or small-bore, connectors, which are compatible among various delivery systems. The Joint Commission released a Sentinel Event Alert this week to communicate this potential for harm.
Currently new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers to minimize the potential for a misconnection, such as attaching a feeding tube into a tracheostomy tube.
The new international manufacturing standards are being introduced in phases and include engineering specifications for small-bore connectors. It will be nearly impossible to misconnect tubing manufactured under the new ISO standards, according to a Joint Commission release.
The FDA has also issued an alert regarding the medical hazard of tubing misconnections.