Intravenous therapy misconnections

August 31, 2008

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The FDA have issued a special edition of ‘Patient Safety News’, they are repeating a number of reports as they are some of the most important safety issues that continue to pose a public health concern.

Luer connectors, fittings and locks are widely used because they are inexpensive and easy to use. But the connector design also makes it easy for unrelated delivery systems to be connected to each other, sometimes with disastrous results.

Some of these incidents occurred when tubing from a portable blood pressure monitor was mistakenly connected to the patient’s IV line, causing fatal air emboli. In another case, an air supply hose from a pneumatic compression device was inadvertently hooked up to a needleless IV tubing port.

Click here for the full Patient Safety News report.

Click here for the ISMP Medication Safety Alert.