FDA Nurse Consultants Publish Article on Luer Connector and Tubing Misconnections
MedSun: Newsletter #15, June 2007

When the Joint Commission issued a Sentinel Event Alert in April 2006 about the widespread occurrence of luer connector and tubing misconnections and potentially deadly consequences, there was new awareness among health care organizations nationwide about this alarming problem.

Three FDA nurse consultants, Beverly Gallauresi, Melissa Eakle, and Audrey Morrison, who have been monitoring such events over the past few years, have published an article in Safe Practices in Patient Care, an online serial publication for nurses. In their article, “Misconnections Between Medical Devices With Luer Connectors: Underrecognized but Potentially Fatal Events in Clinical Practice,” the authors conclude that luer connector misconnections are a well-known issue in patient safety and that misconnections "continue to occur because luer connectors are widely available, easy to use, and inexpensive." Even though the health care industry has not yet reached a consensus on preventing misconnections, the authors advise that the number of luer connector misconnections can be reduced by following Joint Commission recommendations contained in the alert.

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