Resources
Enteral Feeding Misconnections: A Consortium Position Statement
IN: The Joint Commission Journal on Quality and Patient Safety, May 2008
Authors: Peggi Guenther (American Society for Parenteral and Enteral Nutrition), Rodney Hicks (United States Pharmacopeia), Debora Simmons (MD Anderson Cancer Center), Jay Crowley (Food and Drug Administration), Richard Croteau (The Joint Commission), Cathie Gosnell (Safety Institute, Premier Inc) and Timothy Vanderveen (Cardinal Health)
Download Enteral feeding misconnections (.pdf) (369KB)
FDA: Look. Check. Connect. Safe Medical Device Connections Save Lives, January 2009
- Download FDA case studies (.pdf) (1,416KB)
- Download FDA 2009 calendar (.pdf) (1,552KB)
- Download FDA 2009 calendar (.zip archive – all images)
- FDA Luer Connections Web site - http://www.fda.gov/cdrh/luer/
FDA Patient Safety News, (Video), October 2007: “More Patient Deaths from Luer Misconnections”
- Download the FDA video
FDA: Patient Safety News, December, 2005: "Luer Lock Misconnections Can Be Deadly"
- Download the FDA news story (.pdf) (27 KB)
Joint Commission and World Health Organization (WHO) WHO Collaborating Centre for Patient Safety Tubing Misconnections
- Download - Avoiding Catheter and Tubing Mis-Connections (pdf) (469KB)
More information: http://www.jcrinc.com/27660/JCRnews/28699/
Joint Commission Sentinel Event Alert, April, 2006:
Tubing misconnections: A persistent and potentially
deadly occurrence
- Download the JCAHO alert (.pdf) (44 KB)
Joint Commission: Draft 2008 National Patient
Safety Goals
- Download the draft NPSG (.pdf) (80 KB)
Misconnections Between Medical Devices With Luer Connectors: Under-recognized but Potentially Fatal Events in Clinical Practice
In: Safe Practices in Patient Care. July 2007, Vol. 3, No. 2.
Authors: Gallauresi, Beverly, R.N., B.S., M.P.H., Eakle, Melissa, R.N., M.B.A., M.S.N., Morrison, Audrey, R.N.,
- Download Misconnections Between Medical Devices (,pdf) (1,139KB)
Preventing Misconnections of Lines & Cables
This guidance article from ECRI (Health Devices. March 2006, Volume 35, Number 3) includes a thorough review of the tubing misconnection problem, as well as prevention and risk reduction strategies including:
- Overview of the problem
- Types of misconnections
- General preventive approaches
- Specific preventive steps
- Risk assessment tools and strategies
- Comprehensive bibliography
For reprint or subscription information, contact ECRI's Membership Services Department at
(610) 825-6000, ext. 5891.
Promoting safer measurement and administration of liquid medicines via
oral and other enteral routes: Patient safety alert from the National
Patient Safety Agency, National Health Service, Great Britain
Patient safety alert 19 requires the use of oral syringes for the measurement and administration of medications via the oral / enteral route to eliminate the possibility of misconnection and inappropriate IV administration of oral medications. Additionally, it requires that enteral feeding systems not contain ports that can be connected to intravenous syringes or have end connectors that can be connected to intravenous or other parenteral lines. Clinical outcomes are presented for 33 cases of oral/enteral to IV misconnections reported between January 2005 and May 2006.