Home
CHPSO
More options
Header link

Contact us

August 9, 2012
  • Read more
Header link

Newsletter sign up

August 22, 2012
  • Read more
Header link

Member log in / sign up

October 12, 2012
  • Read more
CHPSO
  • Home
    • Contact List
    • Patient Safety Work Product
    • Health IT
    • Scheduled Meetings
      • Past Meetings
  • Knowledge center
    • Safe Table Forums
    • Addressing specific risks
      • Blood products
      • Hand hygiene
      • Medical device safety
      • Medication safety
        • Pain management and sedation
        • Anticoagulation
        • General medication safety
        • Infusion pumps
        • Labeling and packaging
        • Small Bore Connectors
        • Storage
      • Other
      • Perinatal safety
      • Surgical safety
        • Retained surgical items
        • WHO surgical checklist
    • Becoming a safer organization
      • Human factors
      • Leadership
      • Safety culture
      • Transparency
      • Working as a Health Care Team
    • Lessons Learned
    • Patient Safety Act
      • Common formats
      • Definitions
      • Case Law & Analysis
      • Laws and regulations
      • Sample policies and procedures
    • Useful links
      • Consumer organizations
      • Hospital associations
      • Improvement resources
      • Literature
      • Newsletters
      • Organizations focused on patient safety
      • Oversight and accreditation
      • Quality and safety data
  • Member resources
    • Safety Event Report Evaluations
    • Current initiatives
      • Independent Peer Review
        A partnership with the American Medical Foundation Patient Safety Organization
      • Safe Table forums
    • Useful tools
    • Ask CHPSO
  • News & events
    • Newsletters
    • Alerts
    • About the Patient Safety Chronicle
      • The Patient Safety Chronicle
    • Upcoming events
    • Past Webinars
  • About CHPSO
    • Connect to CHPSO
    • Partners
    • Prospective members
    • Member listing
        • Colorado
        • Connecticut
        • Georgia
        • Illinois
        • Iowa
        • Kentucky
        • Missouri
        • New Jersey
        • New Mexico
        • Ohio
        • Pennsylvania
        • Rhode Island
        • Tennessee
    • CHPSO staff
    • Career opportunities
    • NAPSO
    • Contact
    • Privacy Policy

Small Bore Connectors

Overview

Small Bore Connectors

September 6, 2016
  • Read more
Post

Use Enteral Device Connectors that Reduce Risk of Misconnection
Patient Safety Alert

September 7, 2018

Misconnections between enteral devices and other devices (e.g., IV), while rare, can have catastrophic consequences. In recognition of this, California has a law prohibiting hospitals and skilled nursing facilities from using enteral feeding connectors that would fit into other types of connectors (e.g., intravenous), unless an emergency or urgent situation exists and the prohibition would impair the ability to provide health care.

  • Read more
Post

Tools for Adoption
Contributed by hospitals

November 16, 2017

Sharp HealthCare

  • Read more
Post

Small Bore Connectors Transition Plan
White Paper

August 22, 2017

This White Paper is a translated and edited version of a guideline document drafted by the German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit/APS). It contains guidelines intended for all parties involved with the complex changeover to ISO 80369 connectors and it aims to contribute to patient safety across the different healthcare applications.

  • ISO Guideline for the implementation of medical products using small bore connectors specified in the ISO 80369 series
  • Read more
Lessons Learned

Echoes of Past Disasters

April 9, 2017

Case 1: Two patients were to receive intrathecal methotrexate with fluoroscopic guidance, Patient A in the morning and Patient B in the afternoon. The pharmacist dispensed the two methotrexate doses and the syringe for Patient A was delivered to his ward that morning. However, the syringe was not delivered before Patient A was transported to radiology. When Patient A arrived in the radiology suite, the technician called over to pharmacy looking for Patient A’s medication. In the pharmacy, the tech saw a single syringe labeled for intrathecal use and delivered it to radiology.

  • Read more
Post

ENFit Progress

April 9, 2017

Supply of the new ENFit connectors, designed to increase patient safety by preventing accidental connection of enteral feeding solutions and medications to intravenous lines, continues to improve. Some hospitals, having identified reliable supply of all the devices needed for safe patient care, have switched over to the ENFit connector.

Please fill out a brief CHPSO survey so that we can gather current information on the status of adoption in California and identify where assistance is needed.

  • Read more
Post

The New Enteral Connectors
February Status Report

February 9, 2016

Responding to concerns that feeding solutions and epidural local anesthetic solutions were potentially fatal when inadvertently administered intravenously, California passed a law establishing deadlines for the adoption of different connectors for these different applications.

  • Read more
Post

June 2015 Enteral Connectors Update

June 11, 2015

There have been recent important developments in deployment of the new, safer, enteral connectors. As of January 2016, California law prohibits hospitals and skilled nursing facilities from using enteral feeding connectors that would fit into other types of connectors (e.g., intravenous), unless an emergency or urgent situation exists and the prohibition would impair the ability to provide health care.

  • Read more
Post

Transitioning to New ISO Connector Standards

October 31, 2014

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.

  • Read more
Post

Reducing the risk of misconnections

August 1, 2013

The Association for the Advancement of Medical Instrumentation (AAMI) has a set of resources related to the risk of small bore connector misconnections. Luer connectors are used for varied applications, some of which are fundamentally dangerous if used in the wrong context. For example, and inflator for a blood pressure cuff can rapidly produce a fatal air embolus if misconnected to an IV line instead.

  • Read more
  • Go to AAMI site on small bore connectors

Medication safety

  • Pain management and sedation
  • Anticoagulation
  • General medication safety
  • Infusion pumps
  • Labeling and packaging
  • Small Bore Connectors
  • Storage

Stay connected

Social Link

LinkedIn

September 12, 2012
  • Read more
Social Link

Twitter

September 12, 2012
  • Read more
Social Link

Facebook

September 12, 2012
  • Read more
Footer link

Newsletter sign up
Sign up to subscribe. A CHPSO email will confirm your subscription.

August 22, 2012
  • Read more
Footer link

Hospital Quality Institute
CHPSO is a division of the Hospital Quality Institute

July 11, 2014
  • Read more
Footer link

Prospective members
CHA & Regional Hospital Association members join CHPSO at no charge.

August 22, 2012
  • Read more
Contact Info

California Hospital Patient Safety Organization
1215 K Street, Suite 800 Sacramento, CA 95814

August 22, 2012
  • Read more

Commands

  • Support portal
  • Log in

Log in

  • Create new account
  • Request new password