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INTRODUCTION
RESOURCES ACKNOWLEDGEMENTS
Hospitals and other healthcare facilities depend on Until standards are completed and manufacturers
a variety of catheters, tubing and syringes to deliver design and produce products that can’t be miscon- Gallauresi, Beverly, R.N., B.S., M.P.H., Eakle, Melissa, R.N., The 2009 FDA Safe Medical Device Safety Calendar
medications and other substances to patients through nected, all interested parties must continue their efforts M.B.A., M.S.N., Morrison, Audrey, R.N. Misconnections Working Group:
vascular, enteral, respiratory, epidural and intrathecal to keep these dangerous misconnections from hap- Between Medical Devices With Luer Connectors: Under- Beverly Gallauresi, R.N., M.P.H.
delivery systems. These delivery systems frequently pening. “Actions must be taken at the patient bedside, recognized but Potentially Fatal Events in Clinical Practice, Anita Rayner, M.P.H.
employ fittings called Luer connectors to link various within all levels of health care organizations and Safe Practices in Patient Care. July 2007, Vol. 3, No. 2. Alex Koustenis
system components. The male and female com- throughout the channels of regulation, manufacturing http://www.safe-practices.org/SafePractice8.pdf Barbara Richards
ponents of Luer connectors join together to create and distribution of these devices in order to eradicate Aron Yustein, M.D.
secure yet detachable leak-proof connections. Multiple the serious problem of tubing misconnections,” said The Joint Commission Sentinel Event Alert. Tubing Jay Crowley , M.S.
connections between medical devices and tubing are Peter B. Angood, M.D., Vice President and Chief Patient Misconnections—A Persistent and Potentially Deadly Jill Marion
common in patient care. Safety Officer for The Joint Commission (TJC). Occurrence. April 3, 2006, Issue 36. Edie Seligson
http://www.jointcommission.org/SentinelEvents/ Nancy Pressly
Unfortunately, because Luer connectors are ubiquitous, This Medical Device Safety Calendar is one of those SentinelEventAlert/sea_36.htm Susan Gardner, Ph.D.
easy-to-use and compatible between different delivery efforts. The calendar provides a graphic depiction of
systems, clinicians can inadvertently connect wrong misconnection cases that have occurred, coupled with ISMP Medication Safety Alert! Problems Persist With Calendar Design:
systems together, causing medication or other fluids recommendations from TJC on ways to prevent these Life-Threatening Tubing Misconnections. June 17, Bonnie Hamalainen
to be delivered through the wrong route. Such errors types of errors. 2004. http://www.ismp.org/newsletters/acutecare/ National Institutes of Health (NIH), Division of Medical Arts
have occurred in diverse clinical settings, causing articles/20040617.asp
serious patient injuries and deaths. The Food and Drug We hope you’ll post the Medical Device Safety Calen- Photography:
Administration (FDA), The Joint Commission (TJC), dar as a year-long reminder to staff that these errors WHO Collaborating Centre for Patient Safety Solutions. Ernie Branson
the Institute for Safe Medication Practices (ISMP), the can occur in any clinical setting. We also urge you to Patient Safety Solutions. Avoiding Catheter and Tubing National Institutes of Health (NIH), Division of Medical Arts
United States Pharmacopeia (USP), the ECRI Institute use the case synopses and recommendations as on- Misconnections. May 2007, Vol. 1, Solution 7.
and others have all received reports of misconnec- going training materials. To that end, we have made the http://www.ccforpatientsafety.org/fpdf/presskit/PS- Special Thanks to:
tion errors. The problem is well-known and well- photos, case studies and additional resources available, Solution7.pdf Dorothy Brownlie, RN, CCRN
documented. Yet despite efforts on the part of FDA and free of charge, at www.fda.gov/cdrh/luer. We encour- Montgomery General Hospital, Olney, MD
other organizations to reduce misconnections through age you to visit this web site to download and make FDA Patient Safety News. More Patient Deaths from Luer for providing technical support
education, protocol and monitoring, the use of Luer further use of these materials. Misconnections. October 2007.
connectors in incompatible medical delivery systems http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/
continues to create situations where dangerous mis- Let’s continue to work together to prevent these transcript.cfm?show=68#5 key
connections can, and do, occur. tragic errors. Each month cites a Misconnection error based on an
Association for the Advancement of Medical actual reported event:
To further reduce the occurrence of these misconnec- Instrumentation (AAMI). ISO/IEC small bore connector
tions, FDA is actively participating in an international new work proposal package including contact information. event
effort to develop and implement standards for non- August 2006. http://www.aami.org/Applications/
interchangeable connectors for small bore medical Daniel G. Schultz, M.D. CommitteeCentral-app/Documents/SBC_PA.pdf Example of the misconnection error;
Potential for Harm is also cited
connectors. A joint working group established by the Director, Center for Devices and Radiological Health
International Organization for Standardization (ISO) U.S. Food and Drug Administration International Organization for Standardization (ISO).
and the International Electrotechnical Commission ISO/CD 80369-1. Updated 2008. http://www.iso.org/ case study
(IEC) leads this effort to develop a series of standards iso/iso_catalogue/catalogue_tc/catalogue_detail.
Bulleted description of the specifics pertinent to each event
for incompatible connectors used in intravascular (IV), htm?csnumber=45976
breathing systems, enteral, urethral/urinary, cuff infla-
tion and neuraxial applications. Once implemented, Medical Device Safety Calendar 2009 the joint commission safety tip
these connectors will facilitate correct connections and http://www.fda.gov/cdrh/luer
Safety tip from The Joint Commission (TJC) to help prevent
eliminate incompatible tubing misconnections. event recurrence
event
High
case study
WARNING: Photographs depict feeding tube erroneously • The feeding tube was inadvertently
connected to trach tube. DO NOT DO THIS! placed in the trach tube and milk
was delivered into the infant’s lungs
• The infant died
January 2009
su m tu w th f sa
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 31
event
Epidural tubing
erroneously connected
to IV tubing
potential for harm
High
case study
February 2009
su m tu w th f sa
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
event
IV tubing erroneously
connected to trach cuff
potential for harm
High
case study
March 2009
su m tu w th f sa
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
event
IV tubing erroneously
connected to nebulizer
potential for harm
High
case study
April 2009
su m tu w th f sa
1 2 3 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25
26 27 28 29 30
event
Oxygen tubing
erroneously connected
to a needleless IV port
potential for harm
High
case study
May 2009
su m tu w th f sa
1 2
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
/31
event
case study
June 2009
su m tu w th f sa
1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30
event
IV tubing erroneously
connected to
nasal cannula
potential for harm
High
case study
July 2009
su m tu w th f sa
1 2 3 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25
26 27 28 29 30 31
event
IV tubing erroneously
connected to enteral
feeding tube
potential for harm
Moderate
case study
August 2009
su m tu w th f sa
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
/30 /31
event
Syringe erroneously
connected to trach cuff
potential for harm
High
case study
September 2009
su m tu w th f sa
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30
event
Foley catheter
erroneously connected
to NG tube
potential for harm
Low
case study
October 2009
su m tu w th f sa
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 31
event
November 2009
su m tu w th f sa
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
event
Pulsatile anti-embolism
Success story! stocking erroneously
connected to IV
These photos show
heparin lock
that PAS pump tubing
potential for harm
is now NOT CAPABLE
of connecting to
can’t connect
High
IV vascular access
devices. case study
can’t connect
December 2009
su m tu w th f sa
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 31