joint commission warns about dangers of tubing misconnection

A few weeks ago, the Joint Commission, the renowned non-profit which certifies and accredits health care facilities across the U.S., issued one of its Sentinel Event Alerts concerning a piece of medical equipment that can be found in virtually every hospital room across the nation.

The medical equipment in question is the tubing used for everything from feeding to the administration of intravenous drugs. According to the Joint Commission, there is a very real — and very deadly — risk of staff members committing accidental tubing misconnections.

For example, an IV tube could be inadvertently connected to the site of an epidural or a tracheostomy tube could be inadvertently connected to a feeding tube.

Indeed, the Joint Commission identified the risk posed by accidental tubing misconnections as being especially acute given the reality that medical tubing can be found in so many settings outside of the hospital, such as nursing homes and even the homes of patients.

Fortunately, help is on the horizon, as the International Organization for Standardization recently developed new manufacturing standards governing tube connectors in an attempt to reduce these accidental tubing misconnections. These new tube connector standards, which are to be introduced in phases, will serve to make it virtually impossible for tubing tasked with differing functions to connect.

As it turns out, the first phase of these new ISO standards is scheduled to be introduced next month.

While you might think this would be cause to celebrate, the Joint Commission has indicated that it should actually serve as a time of heightened vigilance for both hospital and medical staff as the use of the old tube connectors will continue until such time as supplies run out. Furthermore, it cautions that temporary adapters will likely need to be used for a short time to connect the new products with the old, creating additional opportunities for mistakes.

“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 the president and CEO of the Joint Commission. “Organizational leadership is the first line of defense in this transition to the new connectors.”

It will be interesting to see if the new tube connectors help reduce this patient safety risk and how effectively hospitals manage this ongoing danger.

Source: Infection Control Today, “Joint Commission alerts organizations to tubing misconnection risks,” Aug. 19, 2014

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