September 2005, Volume 35 Number 9 , p 73 - 73
EAKLE, MELISSA RN, MBA, MSN; GALLAURESI, BEVERLY ALBRECHT RN, BS, MPH; MORRISON, AUDREY RN
LUER FITTINGS, connectors, and locks are small, inexpensive, and convenient. These devices can easily connect many medical devices, components, and accessories. Unfortunately, because they're so easy to use, clinicians may mistakenly connect the wrong devices, delivering a substance through the wrong route. Such an error can cause serious injury or death.
What can go wrong?
The Food and Drug Administration (FDA) has received reports of enteral feeding tubes mistakenly connected to I.V. lines and tracheal tube pilot balloons. Other reported errors involving luer connections include connecting oxygen tubing to endotracheal tube pilot balloons, noninvasive blood pressure (BP) cuffs connected to I.V. lines, and drugs intended for I.V. administration given intrathecally. Many similar adverse events may not have been reported because the event was attributed to user error.
Here are a few examples ...