Let’s Get Clinical: Improving patient safety by reducing the risk of tubing misconnections


Patricia Kienle, RPh, MPA, FASHP

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

Our "Let's Get Clinical" series shares expert knowledge on medication and patient safety issues that pharmacists face, every day. This post shares insight into how pharmacists can reduce patient safety risks caused by tubing misconnections.

New international design standards for medical device tubing connectors have been developed, with the goal of improving patient safety by reducing the likelihood of tubing misconnections. These new ISO standards apply to small-bore connectors: those tubes and ports that have an inner diameter of less than 8.5 mm. Examples of these devices include IV tubing, feeding administration sets, epidural catheters, and tracheostomy tubes. Various types of connectors will be changed over a multi-year period. Enteral tubing connectors will be changing in 2015.

History of misconnection errors

Luer connectors have been commonly used for years. They are available as both locking and slip connectors:

Though convenient, errors have been reported when the connectors have been inadvertently attached to unintended lines, such as an enteral feeding tube connected to IV tubing.

The luer connectors will be retained for intravascular and hypodermic use. Connectors for other routes of administration will be converted to route-specific connectors. Enteral feeding connectors will be the first introduced to the market, followed by neuraxial applications, respiratory and gases, then limb cuff inflation applications.

New enteral connectors

Since 2012, the nutrition end of enteral feeding connectors has included a site-specific connector. Starting in 2015, the patient-access end of enteral connectors will be changing. A transition set will be available to bridge the time between availability of the old sets and new connectors. The syringes used to administer medications through enteral tubes will now require an enteral-specific connector.

Pharmacy issues

When pharmacy is asked to supply medications in liquid form, it is often not known if the medication is being administered orally or through an enteral tube. Oral syringes typically have a luer connector, which is acceptable. However, if the medication needs to be administered through an enteral tube, the new connector will be needed.

New connectors for patient access end of enteral feeding systems

This is a temporary set to allow connections to current feeding ports until new enteral feeding tubes are available.

This set will change from a male connector to a female new standard connector. The feeding tube port for the administration set will change from female to male.

This is a temporary set to allow connections to current feeding ports until new enteral feeding tubes are available.
Participate in your health-system’s discussion about the enteral connectors. Be sure your Products Committee is aware of the change.

Key actions pharmacists can take:

  • Identify how the need for liquid medications is communicated to you. You need to know if the medication is being administered orally, or if it is being administered through an enteral connector. This may involve changes in your order sets and may involve additional routes of administration in your computer system.
  • Be sure the information is consistent in the ordering, dispensing and medication administration record views of your electronic systems.
  • Assess the oral and enteral syringes that you stock. You will likely need to make some changes in what you use to dispense some liquid doses.
  • For the most current information, link to www.StayConnected2014.org