The commission made a special note of the so-called "spaghetti syndrome," in which providers position functionally dissimilar tubing in close proximity. Failure to recheck or trace tubing connections to make sure they begin and end at the appropriate locations is a failure often occurring during the handoff process or during times when patients are transferred or transitioned from one care setting to another.
"Less-than-optimal reporting of adverse events and near misses as part of efforts to educate and raise awareness" thwarts improvement, the agency said. "There is still a fear of repercussions and legal action."
The commission suggests that hospitals take the following actions to prepare for the new ISO connector standards.
1. Create an interdisciplinary task force to identify potential misconnection hazards and develop strategies to mitigate them. Also conduct acceptance testing for performance, safety and usability on new tubing and catheter purchases.
2. Prepare for ISO connector changes by increasing awareness for clinicians, administrators, supply chain, healthcare technology management and support staff.
3. Assess existing systems, processes and protocols to carefully transition to the new connectors. Find out what each supplier will do to help the transition. Train clinicians and supply chain management on transition plans, including the use of temporary adapters.
4. Purchase only equipment that will conform to the new standards and avoid buying equipment with luer lock connectors for limb cuff inflation, neuraxial, enteral, breathing systems, and pressurized gasses applications. Luer connectors will continue to be used for intravascular or hypodermic applications.