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Strategies for Transitioning to New Tubing Connectors

Strategies for Transitioning to New Tubing Connectors

Tubing and catheter misconnections errors occur with significant frequency as reported by the FDA, the Institute for Safe Medication Practices (ISMP), United States Pharmacopeia (USP), ECRI and The Joint Commission.

As manufacturers introduce devices with new connectors, it is important that healthcare organizations take the appropriate steps to ensure a seamless transition from non-standardized connector designs. Keys to a successful transition include planning, communication, and training.

Healthcare organizations should consider the following strategies:

  • Work with suppliers to develop a plan for removing devices with old connector designs from inventory and replacing them with devices with the new connectors.
  • Promote early coordination between the staff that obtains and maintains medical devices and the staff that uses the medical devices to ensure adequate inventory levels as devices with new connectors for therapeutic groups are introduced. The patient safety and quality assurance staff should be alerted to the transition, in order to make any relevant changes to their procedures.
  • Develop a plan to ensure that all clinicians and providers are informed of the transition to devices with new connectors.
  • Ensure all clinicians and providers are trained in advance of introducing medical devices with new connectors to avoid any interruption in therapy.
  • Advise all staff: DO NOT modify or adapt the medical device or its connector outside of its intended use, in order to prevent misconnections.
  • Educate all staff using the FDA’s ACT protocol:
    • Assess equipment:
      • Assess and clearly label each device, including low-risk devices and high-risk catheters
    • Communicate:
      • Ensure good communication between healthcare staff during patient transfer (hand-off communication, line reconciliation)
      • Inform non-clinical staff, patients, families and caregivers they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or tubing
    • Trace:
      • Trace a tube from the patient to the point of origin:
        • Before connecting or reconnecting any device or infusion, vigilantly check and recheck luers to ensure proper connections prior to each use
        • At any transition, such as to a new setting or service
        • As part of the hand-off communication

Additional Resources:

Case Studies Describing Device Misconnections

Global Enteral Device Supplier Association

Joint Commission Sentinel Event Alert Issue 53

 

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