Managing Risk During Transition to New Tubing (Small Bore) Connector Standards:
What You Need To Know!
The Joint Commission issued Sentinel Event Alert #53 on August 20, 2014, to address safety concerns as the first phase of the change in the small bore connector standards, which began in the 4th quarter of 2014 and the 1st quarter of 2015 with enteral feeding tubes. Changes in epidural tubing connections will follow. Other connectors affected will involve intravenous connections, blood pressure tubing, and breathing systems. These standards were changed in response to recurring high severity patient safety events where different tubings were misconnected to the wrong infusion (http://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf).