Medical Devices

Examples of Tubing and Luer Misconnections

These case studies are based on reports of adverse events received by the FDA1. The potential for harm designations: High, Medium and Low refer to the severity of patient harm that could result from the depicted type of misconnection.

These case studies are also available in high quality printable PDF format (1.32MB).

Prompt reporting of misconnection events, including “near misses” and device use errors, can help the FDA identify and better understand risks associated with medical devices. To submit a report, visit the page titled “Report a Problem to the FDA.

1These case studies can be used without permission from the FDA. They are a product of the U.S. Federal Government and are NOT copyrighted or restricted in any way.


Feeding Tube Erroneously Connected to Trach Tube

Feeding tube erroneously connected to trach tube on baby mannequin.

CASE STUDY

  • An infant in the pediatric intensive care unit had both a feeding tube and a trach tube
  • The feeding tube was inadvertently placed in the trach tube and milk was delivered into the infant’s lungs
  • The infant died

POTENTIAL FOR HARM: High

THE JOINT COMMISSION2 SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion

2The Joint Commission is an independent, not-for-profit organization, which accredits and certifies more than 19,000 health care organizations and programs in the United States.


Epidural tubing erroneously connected to IV tubing


 

Epidural tubing erroneously connected to IV tubing on mannequin arm.

CASE STUDY

  • An anesthetist and a midwife mistakenly connected an epidural set to the patient’s IV tubing
  • The epidural medicine was delivered to the IV
  • The patient died

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: For certain high-risk catheters (e.g., epidural, intrathecal, arterial), label the catheter and do not use catheters that have injection ports


IV tubing erroneously connected to trach cuff

IV tubing erroneously connected to trach cuff on mannequin laying in a hospital bed.

CASE STUDY

  • A child in a pediatric intensive care unit had both an IV line and a trach tube
  • The IV tubing was mistakenly connected to the trach cuff port
  • The IV fluid over-expanded the trach cuff to the point of breaking and continuous IV fluids entered the child’s lungs
  • The child died

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Emphasize the risk of tubing misconnections in orientation and training


IV tubing erroneously connected to nebulizer

Tubing erroneously connected to nebulizer on mannequin laying in a hospital bed.

EVENT: CASE STUDY

  • During a nebulizer treatment, the patient’s oxygen tubing fell off the nebulizer and the patient’s IV tubing was inadvertently attached to the nebulizer
  • When the patient inhaled, a moderate amount of IV fluids was aspirated into the patient’s lungs
  • The misconnection was identified by the respiratory therapist and the patient survived

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Do not purchase non-intravenous equipment that is equipped with connectors that can physically mate or attach with a female Luer IV line connector


Oxygen tubing erroneously connected to a needleless IV port

Oxygen tubing erroneously connected to a needleless IV port on a mannequin arm.

CASE STUDY

  • A patient’s oxygen tubing became disconnected from his nebulizer and was accidentally reattached to his IV tubing Y-site by a staff member who was completing a double shift
  • The patient died from an air embolism, even though the connection was broken within seconds

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Identify and manage conditions and practices that may contribute to health care worker fatigue, and take appropriate action


Blood pressure tubing erroneously connected to IV catheter

Blood-pressure tubing erroneously connected to IV catheter on mannequin arm.

CASE STUDY

  • An ER patient had an IV heparin lock but no IV fluids had been started. The patient also had a noninvasive automatic BP cuff placed for continuous monitoring
  • The BP cuff tubing was disconnected when the patient went to the bathroom
  • When she returned, her spouse mistakenly connected the BP cuff tubing to the IV catheter and approximately 15 mL of air was delivered to the IV catheter
  • The patient died from a fatal air embolus, despite resuscitation efforts

POTENTIAL FOR HARM: High

Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions


IV tubing erroneously connected to nasal cannula

IV tubing erroneously connected to nasal cannula on a mannequin in a hospital bed.

CASE STUDY

  • A nurse’s aide inadvertently connected a patient’s IV tubing to the nasal oxygen cannula upon transfer to the step down unit
  • The misconnection was not noted until four hours later, when the patient complained of chest tightness and difficulty breathing
  • The patient was treated for congestive heart failure and survived

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Recheck connections and trace all patient tubes and catheters to their sources upon the patient’s arrival in a new setting or service as part of the handoff process. Standardize this “line reconciliation” process.


Syringe erroneously connected to trach cuff

Syringe erroneously connected to trach cuff on a mannequin.

CASE STUDY

  • The patient had both a central line with three ports and a trach tube
  • Medicine intended for the central line was inadvertently injected into the trach cuff
  • The trach cuff was damaged and the medicine entered the patient’s lungs
  • A new trach tube was inserted and the patient survived

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion


Enteral feeding tube erroneously connected to ventilator in-line suction catheter

Enteral feeding tube erroneously connected to ventilator in-line suction catheter on a mannequin.

CASE STUDY

  • A patient’s feeding tube was inadvertently connected to the instillation port on the ventilator in-line suction catheter
  • Tube feeding was delivered into the patient’s lungs
  • The patient died

POTENTIAL FOR HARM: High

Emphasize the risk of tubing misconnections in orientation and training


Pulsatile anti-embolism stocking erroneously connected to IV heparin lock

Success story: PAS pump tubing is now not capable of connecting to IV vascular access devices.

CASE STUDY

  • A patient admitted for stroke had a pulsatile anti-embolism stocking (PAS) on the left lower extremity and an IV heparin lock in the right ankle
  • The patient was alert and oriented on admission but shortly after was found unresponsive and cyanotic
  • The PAS pump tubing was found connected to the IV heparin lock in the patient’s right ankle
  • The patient died of a massive air embolus

POTENTIAL FOR HARM: High

THE JOINT COMMISSION SAFETY TIP: Manufacturers should implement “designed incompatibility” as appropriate, to prevent dangerous misconnections of tubes and catheters


IV tubing erroneously connected to enteral feeding tube

IV tube erroneously connected to enteral feeding tube on mannequin in hospital bed.

CASE STUDY

  • A child had both a gastric feeding tube for nutrition and an IV for medicine and hydration
  • When the child’s gown was changed, a family member inadvertently attached the IV tubing to the gastric feeding tube
  • The medicine was delivered through the feeding tube into the stomach
  • There was no patient harm since the event was noted in a timely manner

POTENTIAL FOR HARM: Moderate

THE JOINT COMMISSION SAFETY TIP: Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions


Foley catheter erroneously connected to NG tube

Foley catheter erroneously connected to NG tube on mannequin in hospital bed.

CASE STUDY

  • A patient was found with her Foley catheter disconnected from its drainage bag. One end of the catheter was still in her bladder and the other end was connected to her nasogastric (NG) tube
  • Urine was noted to be flowing into her NG tube
  • The NG tube was connected to suction and more than 300 mL of urine drained
  • The patient’s vital signs were stable and her laboratory results were within normal limits

POTENTIAL FOR HARM: Low

Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions.

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Page Last Updated: 11/01/2013
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