DEVICE SAFETY: Luer-lock misconnects can be deadly
MELISSA EAKLE RN, MBA, MSN
BEVERLY ALBRECHT GALLAURESI RN, BS, MPH
AUDREY MORRISON RN

$3.95
Nursing2014
September 2005 
Volume 35  Number 9
Pages 73 - 73
 
  PDF Version Available!

ABSTRACT
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 ...

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