In 2006, when the birth of her second child was only weeks away, 24-year-old Robin Rodgers began losing weight and vomiting. Her doctor ordered her to be hospitalized and fed through a tube until she delivered. But the nutrition source container that was feeding her via a feeding tube in her stomach was mistakenly connected to an existing intravenous line. Tragically, both Rodgers and her unborn child died. That same year, a Wisconsin nurse mistakenly injected a spinal anesthetic into an IV tube, killing 16-year-old Jasmine Gant, who was giving birth. In another incident, premature infant Chloe Back was mistakenly connected to a bag of breast milk through her IV tube. In this case, the baby did not die, but formed blood clots throughout her body, bled profusely, and suffered seizures for months afterward. In response to these and the many other reports of tubing misconnections that have plagued healthcare workers and human factors engineers for decades, a Sentinel Alert was issued by the Joint Commission in 2006 to draw attention to the gravity of the matter. This year, articles in a number of publications, most prominently the New York Times and Las Vegas Review Journal, have again brought the issue to the forefront. These articles led to a Congressional committee inquiry and a call for new regulations by the Nevada Medical Association. They also prompted the medical device industry and the U.S. Food and Drug Administration (FDA) to publicize the work that has been underway for some time in the development of a new international standard that many hope will virtually eliminate future tubing misconnections. The first of a series of new standards is currently at final voting (FDIS) stage internationally, and will be issued after approval under the designation and title ISO 80369-1, Small-bore connectors for liquids and gases in healthcare applications. Other parts of the series will address connectors for specific applications. In the meantime, 80369-1 is expected to provide unprecedented methods to identify specific connector solutions for a variety of medical applications. Brad Noe, technical resources manager at Becton Dickinson and Company, is co-chair of the AAMI small bore connectors working group, which serves as the U.S. technical advisory sub-group (sub-TAG) for the ISO/IEC connector standards, and is also project leader for two of the ISO/TC 210 project groups developing the series. Noe says that human error due to device issues, environment of care, and other factors certainly plays a part in such misconnections, although “how much a part,” he says, “is difficult to quantify. The misconnection of tubing sets due to working in dimly lit conditions, inability to trace the line from connection point to connection point, or incorrect or missing labels all contribute,” he explains. AAMI is the secretariat for the international committees that are jointly developing 80369 (ISO/TC 210 and Human Factors Initiatives Aim to Make Tubing Misconnections Old News