The Institute of Medicine’s landmark study, To Err Is Human: Building a Safer Health System,1  put medical errors in the spotlight. As a result, health care professionals have become proactive in examining systems and processes that promote medical errors. Often there is no quick or easy “fix” that can be implemented.

Since August 2003, the Institute for Safe Medication Practices (ISMP) has reported tubing misconnections such as the connection of noninvasive blood pressure tubing connected to a needleless Y site of IV tubing.2  In April 2006, The Joint Commission issued a Sentinel Event Alert3  related to tubing misconnections. At that time many of the misconnections involved Luer connectors. In July 2010, the ISMP released a Medication Safety Alert4  with further evidence of harm caused by tubing misconnections.

Help is on the way. The International Organization for Standardization has been working on a standard for small-bore connectors...

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