Wednesday, April 10, 2013

CMS Memo: Luer Misconnection Adverse Events

Last month, CMS issues a Survey & Certification memo to alert providers about Luer tubing misconnections events. Serious events have occurred from wrong tubing connections leading to delivery of incorrect substances or by incorrect routes of administration.

A Luer connector is a fitting for syringes and needles to connect medical devices like IV, enteral, respiratory, etc. components and accessories. Adverse events associated with this connector have occurred. For example, a feeding tube mistakenly was connected to a patient’s ventilator in-line suction catheter and resulted in the delivery of the contents into the patient’s lungs.

CMS recommends that until Luer connection replacements can be fully implemented, try to find an alternative device, have clinicians trace lines back to their origin to ensure correct connection, and position catheter and tubes having different purposes on different sides of the patient’s body.

No comments:

Post a Comment