The Joint Commission is taking a proactive approach to reducing the potential for accidental medical tubing misconnections when new tubing connectors are introduced beginning in October 2014.
In a Sentinel Event Alert issued August 20, titled “Managing risk during transition to new ISO International Organization for Standardization tubing connector standards,” the commission says the risk for tubing misconnection is “high,” given that nearly all patients admitted to the hospital and many in other healthcare settings will receive an intravenous (IV) infusion.
Examples of potentially fatal misconnections include a feeding administration tube mistakenly connected to a tracheostomy tube, or an IV tube connected to an epidural site.
“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,” Mark R. Chassin, MD, The Joint Commission president and CEO, said in a statement.
“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,” he added.
A High-Risk Transition Period
Currently, accidental tubing misconnections may occur because medical tubes with different functions can easily be connected with luer-style connectors used to make leak-free connections between medical tubing. The tubing connections can also be rigged using adapters, tubing, or catheters, the commission notes.
In an effort to prevent tubing misconnections, the ISO has developed new international manufacturing standards for connectors. The new connectors manufactured under the ISO standards will make it nearly impossible to connect tubing delivery systems that serve different functions, The Joint Commission says.
However, while the new connectors are being introduced in the US beginning in October 2014, the old connectors will remain in use until supplies are depleted, raising concerns about the potential for misconnections during this period, they note.
“Due to the continuing risks, The Joint Commission urges health care organizations to be vigilant and begin planning for the transition to the new connectors, which will introduce changes and new risks into the health care environment. Because the old tubing supplies will be in use until they are depleted, temporary adaptors are being introduced to connect the old tubing with the new tubing and the potential for misconnections will still exist,” the commission says.
The commission is alerting healthcare organizations to begin preparing for the changes in connectors and “do everything possible during the transitional period to avoid tubing misconnections. The benefit of the transition is that, ultimately, the engineered solutions will make systems safer for all patients,” they say.
The new ISO connector standards were a collaborative effort among ISO, the Association for the Advancement of Medical Instrumentation, clinicians, manufacturers, and regulators, including the US Food and Drug Administration. The Joint Commission says they don’t anticipate introducing new accreditation or certification standards related to tubing connectors at this time.
In the Sentinel Event Alert, the commission offers several strategies to help prepare for the new ISO connector standards. They include assessing and managing current risks for injury; assessing and adapting existing systems, processes, and protocols to carefully transition to the new ISO connectors; effective processes and procedures for prevention of misconnections; and implementation of safe practices for the administration of high-alert medications.