New solutions to reduce wrong route medication errors

Abstract

Wrong route medication errors due to tubing misconnections are potentially life-threatening complications that have been made possible by the universal use of the Luer connector. The new International Organization of Standardization standards for small bore connectors, ISO 80369 series, have been developed to reduce the risk of these types of erroneous connections. Tubing connectors for different routes of clinical application will contain differently designed connectors that are physically incompatible. However, design and manufacturing standards have progressed slowly, and clinical roll-outs have been delayed, despite the implementation of California laws to promote their use. We are currently in a state of transition where new connectors for enteral and neuraxial use will be entering the clinical market in the next few years, and increasing use will identify additional patient safety concerns.