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Wrongly Connected Tubing a Major Concern, Says Joint Commission

Sentinel Event Alert cites 117 cases, 21 deaths.

Published: August 27, 2014

A feeding tube connected to a tracheostomy tube? An intravenous tube connected to an epidural site?

Can it happen? It can and it does, says the Joint Commission, which has issued a Sentinel Event Alert about the risks of accidental medical tubing misconnections that can cause severe injury or death. The alert cites reports of at least 117 cases and 21 deaths.

Tubes intended for different functions can easily be connected with luer-style connectors, says the alert, and when connections are more challenging, they can be rigged with adapters, tubing or catheters. The International Organization for Standardization has developed new standards for connectors that, once implemented, will make it nearly impossible to connect tubes that serve different functions, but the new connectors aren't expected to be available until October, and older versions are bound to remain in use for some time.

The Joint Commission says temporary adapters will be available to connect old tubing to new tubing, but that the potential for misconnections will still exist. It's urging facilities to begin planning for the transition and to be vigilant about the ongoing potential for errors with older tubing.

Tubing misconnections are more common than are reported and sometimes misreported as medication errors, it says.

Jim Burger


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