On August 20, the Joint Commission (TJC) published a Sentinel Event Alert regarding the planned transition to unique small bore connectors.
Until now, the luer lock has been the most common connector for introducing fluids or gases into various organ systems. These include but are not limited to intravenous infusions, enteral feedings, epidural or other neuraxial infusions and oxygen and other gases.
In their sentinel alert, TJC has identified 116 cases (and 21 deaths) related to enteral feedings connected to intravenous tubing. Multiple other morbidities and mortalities have also been reported including air embolism from a blood pressure cuff connected to an IV, epidural infusions connected to IV’s, and enteral feedings connected to tracheostomy sites in addition to other serious events.
Over the past several years, the Association for the Advancement of Medical Instrumentation (AAMI), the International Standards Organization (ISO), the FDA, and TJC has worked with biomedical engineers, industry manufacturers, and clinicians (including ASA representatives) to develop a new system of small bore connectors, each of which will be unique to a single organ system. This new process will likely begin before the end of 2014 and start with enteral connectors. Luer locks will still be used for IV systems and for the pilot balloon on endotracheal tubes.
Although TJC does not plan on introducing new accreditation or standards relative to this new system, it is likely that these products will replace the current ubiquitous luer locks. Consequently, hospitals and healthcare staff need to be aware of these new systems. The attached alert from TJC offers information to facilitate the roll out of new small bore connectors.
The practice of anesthesiology has always been on the forefront of initiating systems designs which promote safety without relying on clinician practices. The pin indexing system for attaching gases is a prime example. The ASA is in full support of the new plans to use small bore connectors which are unique to each organ system. However, it will also be important for us to quantify problems with the new system. We urge you to report any issues to the AQI through the Anesthesia Incident Reporting System (AIRS) as you go through this transition, so that we are able to fully evaluate these new designs.
Joint Commission Sentinal Event Alert on Small Bore Connectors: http://www.jointcommission.org/issues/article.aspx?Article=SEbZwmh5keJrli25sRll5L0bz1VFG8AB6qqbZaAWAok%3d
Facts about Small Bore Connectors and Tubing Misconnections (AAMI publication): http://www.aami.org/hottopics/connectors/stay_connected_10152013.pdf
Additional resources: http://www.aami.org/hottopics/connectors/index.html