Menu Close
Patient with Blood Oxygen Monitor and IVs

Tubing Misconnections – Resources

Authors: Peggi Guenther (American Society for Parenteral and Enteral Nutrition), Rodney Hicks (United States Pharmacopeia), Debora Simmons (MD Anderson Cancer Center), Jay Crowley (Food and Drug Administration), Richard Croteau (The Joint Commission), Cathie Gosnell (Safety Institute, Premier Inc) and Timothy Vanderveen (Cardinal Health)
  • CMS in their October 4, 2018 Medicare Learning Network newsletter reminded clinicians about the risk of serious injuries and deaths from luer misconnections and the availability of new products that meet industry standards to reduce patient harm. It refers to the March 2013 memorandum for surveyors.
  • A March, 2013 memorandum advises surveyors to be alert to the possibility of a Luer or tubing misconnection when investigating adverse events involving delivery of an incorrect substance or utilization of an incorrect delivery route. Examples given of actions that can be taken include changing to devices already on the market with alternative connector designs which reduce the likelihood of misconnections of incompatible lines.

This guidance article from ECRI (March 2017) recommends transitioning to the new 80369-3 compliant ENFit connector enteral feeding products and offers strategies for implementation.

GEDSA is a nonprofit trade association formed to establish a voice for addressing issues that face enteral device manufacturers, suppliers, and distributors, and to help introduce international standards for healthcare tubing connectors. Comprised of manufacturers, distributors, and suppliers worldwide. GEDSA developed and executed a communications plan to help organizations, clinicians, administrators, supply chain, and others transition to new ISO standard connectors. This initiative is called Stay Connected. The Premier Safety Institute has joined leading experts from the following organizations to provide support for this initiative: AAMI, The Joint Commission, American Society of Parenteral and Enteral Nutrition (ASPEN), Feeding Tube Awareness Foundation, The Institute for Safe Medication Practices (ISMP) and Novation.

The Stay Connected initiative for using safer connectors is a three-phase program. Through the Aware, Prepare, and Adopt phases, GEDSA will help facilitate a successful transition to safer connectors.

  • GEDSA position statement position statement on the FDA’s 9/7/18 Letter to healthcare providers.
  • Medication Safety Alert, April 9, 2015 This article discusses important safety considerations for hospitals when implementing ENFit enteral devices.
  • Tubing Misconnections Self Assessment for Healthcare Facilities
    This assessment tool developed by the Institute for Safe Medication Practices (ISMP) and Baxter Healthcare’s Clinical Center of Excellence assists healthcare facilities in identifying products and practices that pose a risk of inadvertent tubing misconnections and mitigating potentially known risks. The tool provides users with step by step instructions to perform a modified risk assessment designed to evaluate current delivery systems and mating devices, rate ease of connection and potential for patient harm, and assign a risk priority score.
  • Article: Ongoing Risk: Misconnections of Tracheostomy Pilot Balloon Ports with IV Infusions Can Result in Fatal Outcomes, September 2018

Stay Connected is a program designed to facilitate the transition from medical device applications that allow connection between unrelated delivery systems to new, safer connectors that ensure compatibility and consistency while reducing the likelihood of tubing misconnections. Stay Connected is organized by the Global Enteral Device Supplier Association (GEDSA) in partnership with leading industry organizations. GEDSA invites everyone to stay connected as the tubing connectors are introduced through a three-phase communications program – Aware, Prepare, and Adopt – to ensure a successful transition to safer connectors. Resources include design standards, transition checklists, products, frequently asked questions, case studies, and training videos.

Premier Safety Institute is Retiring

This site is no longer being updated; it is staying available for historical reference until 6/30/2022.

For current information on COVID-19 please visit opens in a new tab

For current information on Sustainability please visit opens in a new tab

For all other subject areas please visit opens in a new tab