Preventing Catheter/Tubing Misconnections: Much needed help is on the way
MedSun: Newsletter #52, September 2010

ISMP Medication Safety Alert!

Luer connector systems, common to many healthcare catheters, tubes, administration sets, extension sets, and syringes, have been at the heart of many catheter/tubing misconnections. At the center of one of the most commonly reported problems is the fact that some manufactured enteral catheters still have ports that only accept parenteral administration sets and syringes. So, even if a liquid medication is prepared in an oral syringe, the medication must be transferred to a parenteral syringe for administration via this type of enteral catheter port, risking the accidental administration of the drug via a parenteral line.

Additional Information:

Preventing Catheter/Tubing Misconnections: Much needed help is on the way. ISMP Medication Safety Alert! July 15, 2010.
http://www.ismp.org/Newsletters/acutecare/articles/20100715.asp

On July 9, 2010, FDA sent a letter to product manufacturers, healthcare practitioners, and hospital purchasing departments that offered advice regarding the prevention of catheter/tubing misconnections:

www.fda.gov/downloads/MedicalDevices/ResourcesforYou/Industry/UCM218631.pdf

FDA Luer Misconnections
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm134863.htm


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