Enteral tubing connection changes: A failure modes and effects analysis.

Abstract

M edical tubing misconnections have been reported for years. Although the problem still exists, the events are likely underreported.1 Misconnections have resulted in death or major harm to patients and have the potential for causing secondary trauma for the nurses who make the error.2-5 The ability for misconnections to occur continues to point to the need for a redesign of current connectors.6 An alert from The Joint Commission was issued to notify healthcare facilities about the risk of smallbore tubing (less than 8.5 mm inner diameter) misconnections and encourage facilities to put plans in place to limit the risk of misconnections and transition to new standards.7 A group of clinicians, manufacturers, and regulators collaborated with the International Organization for Standardization (ISO) and the Association for the Advancement of Medical Instrumentation to develop ISO 80369 standards for small-bore tubing connections.8 Nutrition Safety Solutions