One of the most serious medical errors is when a healthcare worker inadvertently connects the wrong syringe or fluid container to patient tubing, then delivers a substance through an unintended and therefore wrong route of administration. Misconnection incidents are rare, but they do occur and can be highly dangerous.
When a noninvasive blood pressure inflation tube gets connected to an IV line, it delivers air under pressure into the bloodstream and causes an air embolism, which can be fatal. When nutritional formula intended to go to the stomach through a feeding tube is connected to an IV line, it delivers the formula into the bloodstream causing pulmonary embolus and sepsis. When IV fluids are connected to the inflation cuff on a breathing tube and deliver a large volume of fluid to a fixed volume device designed to be filled with air, it creates an airway obstruction.
How could this be happening in modern medicine? Misconnections occur for a variety of reasons, such as line confusion when multiple medical devices are being used, difficulty in distinguishing the proper connection in low-light conditions, and even the well-intentioned helper misconnecting lines after unintentional disconnection. But the most important root cause of misconnections is the universal design of the Luer connector on medical device tubing and syringes.
Named after 19th-century German medical instrument maker, the Luer connector common to healthcare syringes and tubings makes it easy and convenient to administer medication, oxygen, and IV and spinal fluids because everything fits. However, it also introduces vulnerabilities by allowing connections between devices that are not intended to connect.
The good news is that later this year, new design standards from the International Organization for Standardization (ISO) will be implemented. First will be introduction of a new design for feeding device connectors (known as enteral tubing connectors) to prevent the kinds of errors mentioned above. Right now, device manufacturers, FDA, and patient safety groups are working together to make this happen.
The new global standard ensures that all manufacturers of feeding tubes and associated administration sets and syringes will use one standard design for the connector that will be universally adopted into practice. It’s one that does not allow connectivity with any other type of connector.
These changes are part of a larger initiative that will later introduce standards for connectors used in other applications. The Luer connector will continue to be used for vascular connections and most drug injections. Besides the new enteral connectors, over the next few years we will also see introduction of newer connectors specific for spinal and epidural use, respiratory and driving gasses, limb cuff inflation, and urogenital use.
The initiative is designed to reduce tubing misconnections by making sure devices for different delivery systems are not compatible. It’d call it one of the most welcomed changes I’ve seen since entering healthcare.
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