Tubing safety resource released
Small-bore connection issue addressed
A long-term problem with tubing connectors used with IVs, naso-gastric feeding tubes, and other medical tubes that could lead to patient harm or even death is being addressed by a resource released by the Association for the Advancement of Medical Instrumentation (AAMI) and other stakeholders.
So-called luer connectors are used for narrow tubes that allow tubes for one kind of medical tubing to be used with an unrelated system. A design issue has been a problem since at least 2006, when the Joint Commission released a sentinel event alert (https://www.premierinc.com/tubingmisconnections/downloads/jcaho-sentinel-event-issue-36.pdf) related to a wide array of tubing connections, including central intravenous catheters, peripheral intravenous catheters, nasogastric feeding tubes, percutaneous enteric feeding tubes, peritoneal dialysis catheters, tracheostomy cuff inflation tubes, and automatic blood pressure cuff insufflation tubes. At that time, there had been hundreds of reports to a variety of organizations of misconnection issues, and some 10 to the commission.
While new design standards are in the works for small-bore connectors, which will reduce the problem, in the interim, the resource paper — available free at the AAMI website — http://www.aami.org/hottopics/connectors/Stay_Connected_10152013.pdf — for the time being, you have to make do with the old ones. The resource makes clear that even if you think you've never had a problem with your connectors, you should be aware of the potentiality, and prepare for the changes that are coming. "Many tubing misconnections are discovered before there is harm — these are generally not reported," the paper notes. "All organizations are one human error away from a harmful tubing misconnection. All should be concerned about making the care environment safer for patients and clinicians by providing devices that are designed using the principles of human factors engineering"
Among the examples cited in the sentinel event alert by the Joint Commission in 2006: infusion lines inserted into Foley catheter lines, and epidural solutions put into general IV catheter lines.
The first of the newly designed devices — enteral — should be available at the end of this calendar year, according to the AAMI. Further resources will be made available at the organization's website as further instruments come on line or other concerns or issues are brought up or addressed.
