Anita Gupta, DO, PharmD, described tubing misconnections as “a reality” of the practice of anesthesiology and the delivery of treatment in hospitals, long-term care centers and hospital facilities.
However, Dr. Gupta, vice-chair of the Division of Pain Medicine and Regional Anesthesiology and associate professor, Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, in Philadelphia, also noted that these misconnections can be prevented by the implementation of safety checks and quality-control protocols. And that is the essence of the Joint Commission’s Sentinel Event Alert, entitled “Managing Risk During Transition to New ISO Tubing Connector Standards,” which was published on Aug. 20 to coincide with the beginning of the phased implementation of the new International Organization for Standardization (ISO) tubing connector standards. The alert offers several strategies for assessing and managing risk for injury associated with tubing connection as well as processes and procedures designed to prevent misconnections.
In a statement released with the alert, Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO of the Joint Commission, noted, “Tubing misconnections are the root cause of too many episodes of patient harm. Organizational leadership… 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.”
According to the alert, accidental tubing misconnections occur because medical tubes with different functions can easily be connected with luer-style connectors that are used to make leak-free connections between medical tubing. The tubing connections also can be rigged as “workarounds” using adapters, tubing or catheters, and these often can lead to misconnections. For example, the alert highlights more than 100 reported instances of misconnections directing enteral feeding solutions into IV lines.
The new ISO standards were developed through collaboration between the ISO and the Association for the Advancement of Medical Instrumentation as well as clinicians, manufacturers and regulators, including the FDA. The standards include engineering specifications for small-bore connectors with an inner diameter of less than 8.5 mm. The authors of the guidelines hope that new connectors designed according to the standards—which are expected to enter the marketplace in October, according to the Joint Commission—will reduce the risk for connecting tubing delivery systems that serve different functions.
To prepare for the full implementation of the new ISO standards, the Sentinel Alert recommends that health care facilities form interdisciplinary task forces—including nurses, pharmacists, risk management personnel, health care technology management personnel, biomedical engineering experts and purchasing staff—to identify potential misconnection hazards and develop preventive strategies. These task forces also should test new tubing and catheter purchases to assess them for misconnection potential. Finally, the Joint Commission recommends that these task forces lead health care facility initiatives in education on, preparation for and adoption of tubing manufactured according to the new ISO standards.
Additionally, the Sentinel Alert urges health care facilities to adopt safe tubing procedures, including a standardized “line-reconciliation” process that traces any tubing or catheter from the patient to point of origin before connection/reconnection and patient transition to a new setting or service, as part of the hand-off process; this can be accomplished through initiatives such as peer checking or peer coaching. The Joint Commission also recommends routing tubes and catheters having different purposes in different, standardized directions; labeling tubes and catheters; and using tubing and related equipment only as intended.
Experts believe that the Sentinel Alert will have an impact on anesthesiology practice in both the short and long term. Dr. Gupta said that, at her hospital center, many of the Joint Commission’s recommendations for reducing tubing misconnection have been part of standard practice for several years. However, she added, the Sentinel Alert has caused her and her colleagues to revisit the hospital’s quality-control measures to ensure that they have been properly implemented. They also plan to incorporate tubes manufactured according to the new ISO standards as soon as possible and begin adopting steps to address issues such as workplace fatigue.
“A lot of these errors occur as a result of nursing staff and doctors being overworked,” Dr. Gupta said. “Hopefully, this Sentinel Alert will serve as a reminder to the profession about the importance of this issue, and that we as a profession will reinforce our quality procedures. Right now there are no published standards on this issue, so it would be great if this alert drives us toward that.”