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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 10/27/2016 12:00:00 AM

This alert discusses the adverse events that can occur when tubing of medical devices is misconnected. Serious harm or death can result when a medication, substance (such as an enteral feeding) or gas is delivered via the wrong route. The alert identifies major factors contributing to tubing misconnection injuries. International Organization for Standardization (ISO) standards are currently being reworked to prevent misconnections by designing connectors that physically prevent connections with devices used for other medical applications. During the transition to the new ISO standards for tubing connections, healthcare organizations should implement practices to manage the risk of tubing misconnections. The alert provides the Joint Commission risk management tips for clinicians.

Additional Details

Device:
luer connectors, adapters, tubes, catheters


Medical Device Tubing Misconnections May Result in Serious Harm