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Standards to Focus on Tubing Misconnections
 

Small bore connection systems are the most common way of attaching catheters, IV tubes, etc. They consist of small, round "male" and "female" interlocking tubes, slightly tapered to hold the two components together. Misconnections results in creating a high degree of risk of a medication error occurring.

An international effort to create standards designed to minimize the likelihood of life-threatening tubing misconnections in healthcare facilities is under way and gaining momentum.

Advancement of Medical Instrumentation's (AAMI) working group and an International Organization for Standardization (ISO) committee are working together "to develop international standards that create engineering 'forcing functions' that would physically preclude using mismatched tubing sets which results in creating a high degree of risk of a medication error occurring.

According to Brad Noe of Becton Dickinson & Company and co-chair of AAMI , "Our target audience is clinical users, buyers of these products, manufacturers, and those who supply components for use in these applications. This is a globally recognized issue with a corresponding global effort to provide appropriate, workable, and relevant solutions."

The problems with tubing and catheter misconnections have existed for years. However, the issue gained prominence in healthcare facilities when The Joint Commission published an April 2006 Sentinel Event Alert (SEA) that referred to tubing misconnections as a "persistent and potentially deadly occurrence." While the Joint Commission identified just nine actual cases involving tubing misconnections in its SEA, eight of which resulted in patient deaths, it noted that the problem is underreported.

The international committee is currently developing a foundation document that would allow for future expansion and revision as necessary, without having to rewrite the standard.

"This approach takes into account the likelihood of continued expansion and development of new clinical applications and related tubing sets," says Noe.

Noe also points out that "small bore connector teams are being formed to address specific types and groupings of small bore connectors.

Small bore connection systems are the most common way of attaching catheters, IV tubes, etc. They consist of small, round "male" and "female" interlocking tubes, slightly tapered to hold the two components together.

"Given that we are dealing with potential medication errors and potential injury to patients, one can never move quickly enough to create solutions to resolve this. However, the team is extremely aware of their responsibility and is working diligently to reach solutions that are realistic, applicable, and economically sound, and can be implemented with minimal disruption to clinical practice."

The initial international standard, expected to be titled Small bore connectors for liquids and gases in healthcare applications-Part 1: General requirements, is currently under review, with an anticipated publication date of January 2010.

Founded in 1967, AAMI is the world's leading organization dedicated to advancing the safe and effective development and use of medical technology. AAMI's annual conference attracts healthcare professionals from hospitals, universities, consulting firms, independent service organizations, and manufacturing companies around the world.

(http://www.dotmed.com/news/story/6776)

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