The Joint Commission has issued a new Sentinel Event Alert, “Managing risk during transition to new ISO tubing connector standards,” which addresses the risks of accidental medical tubing misconnections that can cause severe patient injury or death.
Two examples of potentially fatal misconnections are a feeding administration tube mistakenly connected to a tracheostomy tube and an intravenous tube connected to an epidural site.
In an effort to prevent dangerous tubing misconnections, the International Organization for Standardization (ISO) has developed new international manufacturing standards for connectors.
The standards are being introduced in phases and include engineering specifications for small-bore connectors with an inner diameter of less than 8.5 millimeters. The new connectors manufactured under the ISO standards will make it nearly impossible to connect tubing delivery systems that serve different functions.
Although connectors manufactured to the new specifications are expected to enter the marketplace by October, the old connectors will remain in use until supplies are depleted. The Joint Commission is alerting health care organizations to begin preparing for the changes in connectors and to do everything possible during the transitional period to avoid tubing misconnections. These new engineered solutions should make systems safer for all patients.
