December 2004, Volume 34 Number 12 , p 12 - 12
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(12) December 2004 p 12 Beware a fatal flaw [MEDICATION ERRORS: NEEDLELESS I.V. ACCESS]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A child was receiving medication via a nebulizer to treat asthma when the oxygen tubing became disconnected from the nebulizer fluid chamber. Later, a staff member accidentally reconnected the loose tubing to the injection port on the child's needleless I.V. access system. The child died instantly. According to the FDA report on this event, the pressure of the oxygen forced the needleless valve open and air entered the tubing, resulting in a venous air embolism.
Oxygen tubing doesn't have a Luer connector, but the manufacturer of the needleless port in this case (Clearlink by Baxter) confirmed that such a connection is possible ...