How Tubing and Luer Misconnections Occur
- Preventing Tubing and Luer Misconnections
- Information for Manufacturers of Small-Bore Connectors and Medical Devices with Connectors
- Recommendations for Health Care Facilities
- Tips for Health Care Providers
- How Luer and Other Small-Bore Connectors are used in Clinical Settings
- How Tubing and Luer Misconnections Occur
- Examples of Tubing and Luer Misconnections
- Factors that Contribute to Tubing and Luer Misconnections
- Report a Problem to the FDA
- Additional Resources
Tubing and Luer misconnections occur when one medical device is mistakenly attached to another medical device that performs a different function. Because these connectors are easy to use and compatible between different medical device delivery systems, clinicians can mistakenly connect unrelated systems to one another, causing medication or other substances to be delivered through the wrong tubing. These errors are sometimes called tubing misconnections, wrong route errors, catheter misconnections or Luer misconnections and can result in patient injury or death.
The FDA has received many reports of serious and even fatal misconnections. For example, an infant died when a feeding tube was misconnected to an IV. For more examples, visit the Examples of Tubing Misconnections page.