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"We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends" Naftalovich et al (2021).

Needlefree connector IV extension set incident

Abstract:

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

Reference:

Naftalovich R, Char S, Iskander AJ, Naftalovich D. Even the Simplest Devices May Malfunction: Split Septum Design Revisited. Biomed Instrum Technol. 2021 Jan 1;55(1):41-43. doi: 10.2345/0890-8205-55.1.41. PMID: 33690818.