Alerts and guidance documents have been issued by numerous governmental, accreditation, professional, manufacturing, and healthcare organizations. They include the following:
• Sentinel Event Alert, Issue 36: Tubing misconnections—a persistent and potentially deadly occurrence from The Joint Commission (TJC)
• Case studies, a safety calendar, videos, webinars, and other resources from the US Food and Drug Administration (FDA)
• Clinical recommendations from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
• A letter to surveyors about the need to review hospitals’ prevention policies from the Centers for Medicare & Medicaid Services (CMS)
• Making Healthcare Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices from the Agency for Healthcare Research & Quality (AHRQ)
Other organizations have published educational material and practice standards describing methods to reduce tubing misconnections. Healthcare providers have implemented educational programs and protocols, such as tracing all lines back to their origin prior to reconnecting devices, or positioning catheters and tubes that have different purposes on different sides of the patient’s body. Some manufacturers use color coding with their connectors. Others have developed proprietary alternative connectors and product designs that are incompatible with Luer connectors for IV delivery systems, which are frequently involved in misconnections. However, these efforts have not eliminated the problem. A design change and correlating standards would make misconnections between unrelated delivery systems (e.g., vascular, enteral, respiratory, epidural, and intrathecal), medical devices, and accessories highly unlikely. Such design changes should be based on specifications and correlating standards. For more information on how design standards are validated, see question 11.
