Tubing and catheter misconnections between patients and medical devices or between devices can lead to serious injury or death. The Joint Commission (jointcommission.org), a standards-setting and accrediting body, issued several alerts addressing the subject. The alerts are part of the Commission's 2008 National Patient Safety Goal proposal which focuses on education, patient-risk assessment, and adherence to procedures to reconcile the lines and tubing prior to use.

The Commission points out that many hospitals use standard luer fittings to connect tubing and accessories. However, the risk for tubing misconnections is great because standard luer connectors are used on a wide range of medical devices and products.

The Commission proposes the following changes:

• Identify potential misconnections through risk assessment of all existing catheters and tubes and when considering the purchase of new catheters and tubing, especially those with luer connections.

• As part of the handoff communication, develop a standard “line reconciliation” process. This action should include rechecking tubing and catheter connections, tracing all patient tubes and catheters to their sources for correct route, and labeling all tubes and catheters at the point of connection.

• Trace all lines from their sources to the patient before making any connections or reconnections, administering medications, solutions, or other products.

• Educate all clinical and non-clinical staff about the hazards of misconnecting tubing and devices.