Important Information on Tubing Misconnections
MedSun: Newsletter #33, February 2009

Luer fittings, connectors, and locks can easily connect many medical devices, components, and accessories. Unfortunately, because they are so easy to use, clinicians may mistakenly connect the wrong devices, delivering a substance through the wrong route. These errors can cause serious injuries and death. The items found in the Additional Information section below have been collected from a variety of sources to provide you with information on this topic, as well as with recommendations on how to prevent these errors.

FDA has developed a 2009 Medical Device Safety Calendar as a means to educate healthcare professionals about these dangerous events. The calendar provides images depicting twelve different misconnection cases in addition to recommendations on ways to prevent these errors. Please visit the FDA Luer Misconnections website to download or print the calendar to use in your healthcare facility.

You are also encouraged to visit the Educational Materials page for a newly posted webcast entitled, “Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events” sponsored by KidNet and presented in November 2008.

Additional Information:

Luer Lock misconnections can be deadly. FDA Patient Safety News. December 2005.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=46#6

Education, Evaluation are Key...Sentinel Event Alert Compels Hospitals to Address Tubing & Catheter Misconnections. Cruise,C. Association for the Advancement of Medical Instrumentation (AAMI), Biomedical Instrumentation and Tech. Vol 42(6). Dec. 2008
http://www.aami-bit.org/perlserv/?SESSID=24b2b52fc78ce4c839884a2e5085643c&request=get-document&doi=10.2345%2F0899-8205-42.6.469

Tubing Misconnections – A Persistent and Potentially Deadly Occurrence. The Joint Commission Sentinel Event Alert. April 3, 2006.
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm

FDA Nurse Consultants Publish Article on Luer Connector and Tubing Misconnections. FDA MedSun website. June 2007.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=15#1

Tubing Misconnection Errors Widely Recognized as Significant Patient Safety Issue. FDA MedSun website. September 2007.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=17#3

A Look at MedSun’s Enteral Feeding Misconnections Survey. FDA MedSun website. September 2007.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=17#4

Blood Pressure Monitor Tubing May Connect to IV Ports. Institute for Safe Medication Practices (ISMP) Medication Safety Alert! June 12, 2003.
http://www.ismp.org/newsletters/acutecare/articles/20030612.asp

Problems Persist with life-threatening Tubing Misconnections. Institute for Safe Medication Practices (ISMP) Medication Safety Alert! June 17, 2004.
http://www.ismp.org/newsletters/acutecare/articles/20040617.asp

2009 Medical Safety Calendar (featuring Luer Misconnections). FDA Luer Misconnections Website.
http://www.fda.gov/cdrh/luer/

Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events. MedSun website: Educational Materials. November 19, 2008.
http://www.fda.gov/cdrh/medsun/AudioConf_files/LuerConnectorMisconnections/index.html


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