Nurses have long been aware that multiple medical devices can fit together using a Luer lock system, increasing the risk of connecting ports that not only do not belong together but also can be lethal to a patient when connected. The Institute for Safe Medication Practices (ISMP) has reported on another case of medical device misconnection in their June issue.1 The patient was connected to a vital sign monitor that had both pneumatic tubing to inflate a blood pressure cuff and an IV line. When the pneumatic blood pressure tubing became disconnected, it was mistakenly connected to the IV catheter. Air entered the patient's IV line and the patient died from an air embolism.

Nurses should work with their purchasing committees to avoid purchasing medical devices that are interconnective. To help reduce errors, IV lines should be labeled, and staff, including nonlicensed staff who work with patients, should be educated about this risk. Nurses should never request that a nonlicensed staff person disconnect or connect medical tubing. Any misconnections should be reported to the Food and Drug Administration's MedWatch program at http://www.accessdata.fda.gov/scripts/medwatch/index.cfm, even if the misconnection did not lead to patient harm.

To read the ISMP's safety alert, go to http://www.ismp.org/nursing/medication-safety-alert-june-2023?check_logged_in=1. Please note, parts of this website require a subscription.

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