FEATURE Cross Connections
International standards to prevent tubing misconnections are expected in 2014. BY SAHELY MUKERJI
L
uer connectors, developed in 1896 by Parisian surgical instru-
ment manufacturer H. Wulfing Luer, are used worldwide today to connect various catheters, tubing and syringes that deliver medications and other sub- stances to patients. They are a critical component of many vascular, enteral, respiratory, epidural and intrathe- cal delivery systems. The connectors, however, are compatible with many different delivery systems. As a result, says Paul Schyve, MD, senior adviser for health care improvement at The Joint Commission, “tubing miscon- nections create a frequent risk to pa- tient safety in light of the many tubing connections that occur every day in inpatient, ambulatory and nursing fa- cility care.” The Luer connector “is like a USB port on your computer; it’s a universal
design,” says Mary Logan, president of the Association for the Advancement of Medical Instrumentation (AAMI) in Arlington, Virginia. “That’s the beau- ty of it and that’s what has turned it
ture review conducted by D. Simmons and K. Graves of the M.D. Anderson Cancer Center at the University of Texas revealed more than 115 separate references to such errors. “From 1995 to date, 11 cases of death or serious permanent harm from tubing misconnections have been re- ported to The Joint Commission—one is currently being evaluated,” Schyve says. “So far, none of the cases are from ambulatory surgery centers, [but] because reporting is voluntary, only a very small percentage of this type of adverse event is reported to The Joint Commission.” The US Food and Drug Administra- tion (FDA), the United States Pharma- copeia (USP), The Joint Commission, the ECRI Institute (formerly the Emer- gency Care Research Institute) and the Institute for Safe Medication Prac- tices (ISMP) all have received reports of misconnection errors. In response, about 4½
½ years ago, an effort to devel- , manager for tech-
op new standards to minimize the risk of tubing misconnections began in Eu- rope, says Brad Noé, manager for tech-
é, manager for tech-
nical resources, Hypodermic Platform at Becton, Dickinson and Company in Franklin Lakes, New Jersey. The firm is a medical technology company that manufactures the connectors and sup- plies them to end-users.
The development process is complicated, given the five different competing connector families, and there’s still design work being done. We are applying the principle of ‘Do no harm’ and trying not to disrupt those clinical practices developed over years of experience.”
—Brad Noé, Becton, Dickinson and Company
into a danger. A nurse can connect the wrong tube to the wrong connector and [that can] result in an unintended consequence.” Tubing misconnections have been reported since 1972. In 2008, a litera-
18 ASC FOCUS NOVEMBER/DECEMBER 2012 Today, a joint working group of the
International Organization for Stan- dardization (ISO) and the International Electrotechnical Commission (IEC), which comprises more than 100 manu- facturers, clinical organizations, aca-
el-
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