A typical patient can be connected to several devices to receive medications, fluids and nutrients. Unfortunately, these tubes can be misconnected. One example of a dangerous misconnection is when a patient received enteral feeding formula intravenously because the tubing intended for the feeding tube was connected to the IV instead. Organizations have tried different strategies to reduce the risk of these misconnections.
Trace tubing or catheter from the patient to point of origin (line reconciliation)
Before connecting or reconnecting any device or infusion
At any transition, such as to a new setting or service
As part of the hand-off process
Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially important in the care of neonates and small children.
The State of California made a commitment to significantly address this patient safety issue by adopting legislation (AB 1867). The purpose of the bill is to prohibit general acute care, acute psychiatric and special hospitals from using an epidural, intravenous or enteral feeding connector that fits into a connection port other than the type for which it was intended, starting in January 1, 2016. Although not mandated in other states, medical device manufacturers/ suppliers are expected to comply with the new California law.
To address this problem, new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers. The intention is to create a mechanical barrier to prevent misconnections. The enteral feeding tubing, for example, simply cannot be attached to an IV because the ends will not connect together.
As with any significant change in process, there are safety risks associated with the implementation of new connectors. GEDSA (Global Enteral Device Supplier Association) developed Stay Connected as a communication platform to help introduce new enteral connectors with the help of leading experts, such as AAMI, ASPEN, ISMP and the Joint Commission. The Stay Connected website (stayconnected2014.org) has valuable resources to assist you with your preparations.