ARLINGTON, VA, USA - (HealthTech Wire) - An international effort to create standards designed to minimize the likelihood of life-threatening tubing misconnections in healthcare facilities is under way and gaining momentum.
According to Brad Noe, co-chair of the Association for the Advancement of Medical Instrumentation’s (AAMI) working group on small bore connectors for liquids and gases in healthcare applications, "we are currently focusing our efforts on those tubing sets that are increasingly prevalent in healthcare settings and, when misconnected, create a high degree of risk of a medication error occurring."
Specifically, Noe indicates that AAMI’s working group and an International Organization for Standardization (ISO) committee are working together "to develop international standards that create engineering ‘forcing functions’ that would physically preclude using mismatched tubing sets.
"Our target audience is clinical users, buyers of these products, manufacturers, and those who supply components for use in these applications," says Noe, of Becton Dickinson & Company. "This is a globally recognized issue with a corresponding global effort to provide appropriate, workable, and relevant solutions."
The problems with tubing and catheter misconnections have existed for years. However, the issue gained prominence in healthcare facilities when The Joint Commission published an April 2006 Sentinel Event Alert (SEA) that referred to tubing misconnections as a "persistent and potentially deadly occurrence." While the Joint Commission identified just nine actual cases involving tubing misconnections in its SEA, eight of which resulted in patient deaths, it noted that the problem is underreported.
The international committee is currently developing a foundation document that would allow for future expansion and revision as necessary, without having to rewrite the standard.
"This approach takes into account the likelihood of continued expansion and development of new clinical applications and related tubing sets," says Noe.
Noe also points out that "small bore connector teams are being formed to address specific types and groupings of small bore connectors.
Small bore connection systems are the most common way of attaching catheters, IV tubes, etc. They consist of small, round "male" and "female" interlocking tubes, slightly tapered to hold the two components together.
"Given that we are dealing with potential medication errors and potential injury to patients, one can never move quickly enough to create solutions to resolve this. However, the team is extremely aware of their responsibility and is working diligently to reach solutions that are realistic, applicable, and economically sound, and can be implemented with minimal disruption to clinical practice."
Forthcoming standards to focus on tubing misconnections
