Joint Commission issues Sentinel alert on medical tubes

The long-standing patient-safety risks posed by improperly connected medical tubes must be addressed by providers, the Joint Commission said Wednesday in a Sentinel Event alert (PDF).

Almost all inpatients are at risk because most receive medicine or other fluids through an intravenous tube during their hospital stay. Prime examples of potentially fatal misconnections cited by the Joint Commission include linking a feeding tube to a tracheotomy line or connecting an IV tube to an epidural source.

“Tubing misconnections are the root cause of too many episodes of patient harm, and the Joint Commission is committed to helping healthcare organizations prevent them,” Joint Commission CEO Dr. Mark Chassin said in a news release.

Manufacturers are introducing new tube connectors that will make it nearly impossible to link different systems serving different medical functions. These products will be introduced over the next two years but, according to the Joint Commission, patient safety risks remain high until existing supplies are depleted. Tubes also can be rigged with adaptors which allow them to be connected to points of potential harm.

The alert cited 116 cases involving misconnected feeding tubes that resulted in 21 deaths. Adverse events linked to tubing misconnections are believed to be underreported, the commission noted.

Healthcare organizations should conduct a risk assessment of their tubes and catheters, the Joint Commission recommended, as well as generating awareness of the issue with their staff. They should also meet with suppliers to learn how they plan to distribute the new connectors and, once the new connectors become available, purchase only products that conform to new standards designed to prevent misconnections.

Follow Andis Robeznieks on Twitter: @MHARobeznieks