Until new connectors are universally adopted in health care facilities, these interventions offer health care providers important tips to prevent device misconnections.

Health Care Providers:

ACT to prevent medical device misconnections! To help reduce risk to patients, consider the following strategies, based on recommendations from The Joint Commission and ECRI Institute, both independent nonprofits that research the best approaches to improving patient care.

Assess equipment

• Assess and clearly label each device, including low-risk devices and high-risk catheters.

Communicate

• Ensure good communication between health care staff during patient transfer.
• 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 prior to connecting any new devices or replacing old ones.
• Vigilantly check and recheck fittings and connectors to ensure proper connections prior to each use.

Clinical Managers:

Risk managers, nurse managers, clinical educators, and similar personnel may consider taking the following steps to help prevent misconnections:

• Tell clinicians, patients and caregivers in home-based or ambulatory care when new devices are intended for use in the health care facility or at home.
• Emphasize the risk of tubing and catheter misconnections in clinical staff orientation and training.

Health Care Facilities:

ECRI Institute recommends that facilities create a multidisciplinary task force—with staff from nursing, risk management, clinical engineering, and purchasing—to identify potential misconnections hazards and develop strategies for combating them. Consider the following actions to help prevent misconnections:

• During initial use, check new devices and equipment to identify potential misconnections and take immediate corrective actions, if necessary.
• Report adverse events and near misses, following your facility protocol.
• Report any issues to the FDA through its MedWatch reporting system.
• Health care personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.