Tubing misconnections
Enteral Feeding Misconnections: A Consortium Position Statement
IN: The Joint Commission Journal on Quality and Patient Safety, May 2008
Download Enteral feeding misconnections
(.pdf) (369KB)
Misconnection of tubing used to link patients to medical devices or medical devices to each other, have the potential to result in serious injury or death. and are believed to be under-reported. Although errors involving various types of tubing and catheters have been reported for over 20 years, there has been a recent increase in awareness of this issue and a call for solutions from governmental agencies, professional organizations, and patient safety groups. In April 2006, The Joint Commission (TJC) issued a Sentinel Event Alert (.pdf) (44 KB) entitled "Tubing misconnections—a persistent and potentially deadly occurrence" that offered strategies for healthcare organizations to reduce risk and called upon manufacturers to redesign products to prevent misconnections.
Medical devices used in hospitals must have the ability to connect to related tubing and accessories –the standard "luer" connector makes this possible. However, because the luer connector is a standard size and is used on such a broad range of medical devices and products with totally different functions, the risk for tubing misconnections is great.
A patient, for example, may be connected to several devices used to administer fluids through a vein; deliver feedings via a tube to the stomach; monitor blood pressure; and administer oxygen via mask or cannula. This collection of devices, all of which may include luer connectors, poses a risk of tubing misconnection especially in a busy clinical environment where stress, fatigue and distractions are common.
Examples of tubing misconnections that may lead to severe illness or death include:
- Liquid feedings or formula intended for a feeding tube or nasogastric (NG) tube into the stomach is accidentally connected to an intravenous (IV) line –delivers liquid feeding into the bloodstream.
- A non-invasive blood pressure insufflation tube is accidentally connected to IV line--delivers air under pressure into the bloodstream causing an air embolism.
- IV fluids are accidentally connected to the inflation cuff on a breathing tube (tracheostomy or endotracheal tube) --delivers a large volume of fluid to a fixed volume device designed to be filled with air (the cuff), causing it to burst with fluid leaking into the airway resulting in airway obstruction.
- NG or tube feedings accidentally connected to a peritoneal dialysis catheter—delivers formula intended for the stomach to the abdominal (peritoneal) cavity.
Collaboration to develop standards
Governmental, professional, and trade organizations along with medical device and product manufacturers are collaborating to develop standards that limit the use of luer fittings to specific devices and design other connectors that are incompatible with luer connections for the remaining devices. Experts agree that the best solution to prevent tubing misconnections is to change the design of the connectors so only devices that should be connected are able to be connected and those devices that should not be connected are incompatible. This design incompatibility would make it easy to make the correct connection and difficult or impossible to make the "wrong" connection or a tubing misconnection.
An international effort will be required to develop standards designed to minimize the likelihood of life-threatening tubing misconnections in healthcare facilities. In 2008, such an effort was initiated when the Association for the Advancement of Medical Instrumentation’s (AAMI) working group on small bore connectors for liquids and gases in healthcare applications and an International Organization for Standardization (ISO) committee began working together “to develop international standards that create engineering ‘forcing functions’ that would physically preclude using mismatched tubing sets.” More details about this effort are available in AAMI News, September 2008 at http://www.aami.org/publications/AAMINews/Sep2008/tubing.html.
The first international standard, related to small bore connectors for liquids and medical gases is currently under development. It has an anticipated publication date of January 2010. Interim product solutions have been developed by several suppliers (see contracted suppliers offering products to reduce the risk of tubing misconnections).
Color coding
Color coding has been used by some suppliers in the U.S. and in Europe as a visual cue, particularly related to the prevention of enteral misconnections. The color orange has been used by some suppliers and hospitals in the U.S. to designate oral/enteral, while purple has been used by some suppliers in Europe. Recently, however, this has added to the confusion as some international suppliers have begun using purple worldwide.
To date, there are no standards in the U.S. or Europe related to color for oral/enteral feeding devices. Color, if used should only be a visual cue and all staff must be educated about the labeling or color-coding process in the institution’s enteral feeding system. The primary solution is designed incompatibility, making the wrong connection impossible.
Consortium Position Statement
Until international standards are developed and manufacturers design and market products that can’t be misconnected, healthcare organizations, government and regulatory agencies and device suppliers must continue to work together to eliminate tubing misconnections through education and changes in practice.
A position paper from a consortium of organizations, brought together by the American Hospital Association, including American Society for Parenteral and Enteral Nutrition (ASPEN), FDA, TJC, United States Pharmacopeia (USP), healthcare providers and manufacturers provides guidance for interim practice solutions to reduce the risk of tubing misconnections - “Enteral Feeding Misconnections: A Consortium Position Statement”,
Resources
Visit our Resource section that provides references, international guidelines, tools and case studies. A list of Premier contracted suppliers offering products to reduce the risk of tubing misconnections, is available in our Contracted suppliers section.