Sentinel Event Alert 53
Tubing misconnections continue to cause severe
patient injury and death, since tubes with
different functions can easily be connected using
luer connectors, or connections can be “rigged”
(constructed) using adapters, tubing or catheters.
This is why new ISO (International Organization
for Standardization) tubing connector standards
are being developed for manufacturers.
Managing risk of
tubing misconnections
during the
transition to
new ISO connector
standards
Managing risk of tubing
misconnections during
while we are waiting for the
transition to
new ISO connector standards
© The Joint Commission, 2014. Reprinted with permission.
As we move toward the tubing/connector
standardization we must remain alert to
issues we see.
When an issue is identified please report
as a PSN and it will be reviewed by safety
and purchasing for resolution and
information sharing to mitigate potential
problems.
See FAQs at stayconnected2014.org
Other questions can be addressed to:
•
•
•
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Ashley Selby - selbya@health.missouri.com
Carey Smith - smithcd@health.missouri.edu
Donna Ianke - ianked@health.missouri.edu
Sue Scott - scotts@health.missouri.edu