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TJC Warns Hospitals of Deadly Medical Tubing Mistakes

Cheryl Clark, for HealthLeaders Media, August 22, 2014

The standards are being developed through a collaboration between the International Organization for Standardization (ISO), the Association for the Advancement of Medical Instrumentation (AAMI), clinicians, manufacturers, and regulators such as the U.S. Food and Drug Administration.

New connectors will reach the market by this fall, followed by "a slow, deliberate and careful transition to each new connector." The period of transition will "introduce new risks into the healthcare environment," the commission cautioned.

Enteral connectors will come first, and for patients with old catheters in place, there will be a temporary adapter to allow continued use.

Some of the documented misconnections include a limb cuff inflation device mistakenly connected to an IV, which resulted in the death of a 71-year-old woman from an air embolism, and epidural solutions connected to a peripheral or central IV catheter.

Causes Cited
The Joint Commission referenced a number of causes of these mishaps, including the fact that the problematic connections are often done as "work-arounds," when appropriate adapters, tubes, or catheters are not available.

Providers make "connection errors after going into 'automatic' mode due to stress, fatigue, or distractions," the agency said. Poor lighting is also to blame.

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