Misconnection

19.12.2017 3 Comments

A date for complete implementation has not been determined, but the transition is on-going and will continue throughout These standards provide design specifications for non-Luer compatible, delivery system-specific connectors for each category. The standard covers the general requirement of non-interchangeability and provides the framework for parts 2 — 7 of the standard, designating a unique connector for each of the following device categories: 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 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. More resources Misconnection of tubing used to link patients to medical devices or medical devices to each other is an underreported medical error, which has the potential to result in serious injury or death. The transition for the first new connectors, those for enteral applications has begun. In , an international initiative led by the Association for the Advancement of Medical Instrumentation AAMI and the International Organization for Standardization ISO began to develop standards designed to minimize the likelihood of life-threatening tubing misconnections in healthcare.

Misconnection


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. More resources Misconnection of tubing used to link patients to medical devices or medical devices to each other is an underreported medical error, which has the potential to result in serious injury or death. Examples of tubing misconnections that may lead to severe illness or death include: The new connectors for neuraxial applications are now available and manufacturers are beginning to transition their product lines. The first international standard, ISO , Small-bore connectors for liquids and gases in healthcare applications: 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. 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. FAQs and resources about new small bore connectors to prevent tubing misconnections The AAMI, ISO international joint working group is making great advances toward eliminating the potential for tubing misconnections and increasing patient safety-the focus of the small-bore connector initiative. The standard covers the general requirement of non-interchangeability and provides the framework for parts 2 — 7 of the standard, designating a unique connector for each of the following device categories: These standards provide design specifications for non-Luer compatible, delivery system-specific connectors for each category. The transition for the first new connectors, those for enteral applications has begun. NG or tube feedings accidentally connected to a peritoneal dialysis catheter — delivers formula intended for the stomach to the abdominal peritoneal cavity. Most of the small bore connector — ISO series of standards parts have been completed.. FAQs , developed by a consortium of organizations, including the Premier Safety Institute are intended to be used as a tool for understanding all aspects of the small-bore connector initiative. In , an international initiative led by the Association for the Advancement of Medical Instrumentation AAMI and the International Organization for Standardization ISO began to develop standards designed to minimize the likelihood of life-threatening tubing misconnections in healthcare. 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. A non-invasive blood pressure insufflation tube is accidentally connected to IV line—delivers air under pressure into the bloodstream causing an air embolism. Additional information and materials developed to assist healthcare organizations with the transition to new products are available on the Stay Connected website. 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. Resources Visit our Resource section that provides references, international guidelines, tools and case studies. 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. Although errors involving various types of tubing and catheters have been reported for over 40 years, a recent increase in awareness of this issue has led to a call for solutions from governmental agencies, professional organizations, and patient safety groups. Each additional standard in the series will focus on connectors for a specific device category and will be released as it is completed. 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. A date for complete implementation has not been determined, but the transition is on-going and will continue throughout

Misconnection


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3 thoughts on “Misconnection”

  1. FAQs and resources about new small bore connectors to prevent tubing misconnections The AAMI, ISO international joint working group is making great advances toward eliminating the potential for tubing misconnections and increasing patient safety-the focus of the small-bore connector initiative. More resources Misconnection of tubing used to link patients to medical devices or medical devices to each other is an underreported medical error, which has the potential to result in serious injury or death.

  2. The new connectors for neuraxial applications are now available and manufacturers are beginning to transition their product lines. 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.

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