Making Safe Connections: New Standards Will Make Tubing Connections Safer

An IV line connected to a tracheostomy tube. Blood pressure tubing connected to a ventilator in-line suction catheter. An IV infusion connected to an indwelling urinary catheter. Hard as it is to imagine, improper connections like these happen. The risk of incorrectly connecting a patient’s tubing is high and can have serious consequences. But new design standards for connectors will significantly reduce the risk.

How Mistakes Happen

Connection errors occur when tubing from one delivery system is mistakenly connected to a delivery system serving a different purpose. Reading stories about tubing mix-ups and the tragedies that they cause will send shivers down the spine of any nurse. The types of tubes and catheters that have been incorrectly connected run the gamut from central intravenous catheters, peripheral intravenous catheters, and nasogastric feeding tubes to percutaneous enteral feeding tubes, peritoneal dialysis catheters, tracheostomy cuff inflation tubes, and automatic blood pressure cuff insufflation tubes.

To be sure, a complex mesh of IV lines, catheters, and cables—known as “spaghetti syndrome”—presents a challenge to nurses who must ensure that all of the connections are correct. The risk of connecting a line to the wrong infusion pump, wrong fluid container, or wrong administration route increases for patients with multiple IV infusions, particularly in critical care settings, but the risk exists in other patient settings as well. One major culprit is the Luer connector, a common type of connector that can too easily connect two unrelated lines. Other contributing factors include:

  • rigging adapters, tubes, or catheters in a way they are not intended to be used
  • not rechecking or tracing tubing when the patient is moved from one setting to another
  • working on “auto pilot” because of stress, fatigue, or distractions.

Efforts to Improve

To address the dangers inherent in tubing misconnections, the International Organization for Standardization (ISO) has led an effort to specify and standardize the design of small-bore connectors. These new ISO connector manufacturing standards are being developed in collaboration with clinicians, the Association for the Advancement of Medical Instrumentation (AAMI), and the U.S. Food and Drug Administration (FDA). The standards will require that connectors be designed so that it is almost impossible to attach lines from one delivery system with another.

Enteral feeding device connectors are the first to be reengineered. The Global Enteral Device Supplier Association (GEDSA), under its Stay Connected initiative, is coordinating this effort with manufacturers of enteral devices who now are redesigning the connectors used to attach feeding tubes. The result is the ENFit enteral feeding device connector. The ENFit connectors will not fit any other type of small bore connector, including the Luer connector, virtually eliminating the possibility of a misconnection. The transition to the ENFit connectors is taking place in three phases beginning in 2015 and continuing through 2016. Each phase will introduce the new standard for a different part of the enteral feeding system.


Industry experts recommend that the new connectors be introduced through a four-step process:

  • Aware—Create awareness about the changes in connectors that are coming among all facility personnel. This should include clinicians, administrators, supply chain and health technology personnel, and support staff. Identify a point person who will be responsible for keeping others informed about progress.
  • Prepare—Assess and adapt existing protocols in preparation for the transition to the new connectors. Assemble a team that can assess existing protocols and identify those that will need to change. Work with supplier representatives to prepare a product-specific transition plan. Arrange for proper training, preferably from the manufacturer, for clinicians and inventory management staff.
  • Adopt—Introduce and adopt the new connectors as the facility’s new standard. Emphasize that the benefits of the new connectors in improving patient safety outweigh the inconvenience of having to adapt to a new system.
  • Measure—Collect and analyze quantitative metrics and feedback to measure the organization’s success in adopting the new standard and to identify ways to improve before the next phase of connector introductions.

Good Practices

As the new connector standards are being phased in, it’s important to remember that the single most important step to prevent misconnections is for clinicians to trace all lines back to their origin before connecting or disconnecting any device or infusion. All lines should be rechecked as part of a standardized line reconciliation process when a patient arrives in a new setting and at shift change. Adhering to a policy of consistently positioning different types of lines in relation to the patient also helps to minimize errors; for example, route IV lines toward the patient’s head and enteral lines toward the feet. Instruct care providers to never force a connection. If the connection can’t be made easily, it probably shouldn’t be made at all.

Education and training on proper techniques to ensure correct tubing connections is critical. Elsevier hosted a webinar, “Adopting New Enteral Connectors,” that provides registered nurses with the knowledge needed to successfully transition to the new ENFit standard small-bore tubing connectors for enteral applications and features experts speakers, including Peggi Guenter, PhD, RN, FAAN, senior director of Clinical Practice, Quality, and Advocacy for the American Society for Parenteral and Enteral Nutrition (ASPEN), and Thomas Hancock, executive director, Global Enteral Device Supply Association (GEDSA). The webinar informs nurses about the new ISO standards applied to medical devices for all patients receiving enteral nutrition and explains the use of these new connectors in enteral nutrition delivery, flushing, and medication delivery. Up-to-date Information on the challenges with pediatric medication dosing and low-volume accuracy along with innovative solutions is also included. To listen to a recording of the webinar, click here. To download the presentation slides, click here.

Add a comment:

Your email address will not be published. Required fields are marked *