Factors that Contribute to Tubing and Luer Misconnections

Health care settings are high-stress environments that present many challenges that contribute to misconnections.

Tubing and Luer misconnections occur for many reasons, including:

• Universal design of Luer and many other small-bore connectors
• Widespread use of Luer and other small-bore connectors with the same size opening
• Increasing complexity of medical treatments that require numerous medical devices with Luer and other small-bore connectors
• Human error which can be caused by a variety of conditions, such as: poor lighting, lack of training, time pressure, or fatigue

In a typical hospital setting, many diverse types of medical devices with Luer and other small-bore connectors may be in use at the same time for diagnosis or treatment of a patient.

Specialized hospital settings, such as intensive care units (ICUs), often require the use of more Luer-connected devices than simpler health care settings. For example, it is estimated that in a cardiac care unit there are as many as 40 connectors on devices used with a single patient¹.

Manufacturers and health care facilities have tried many methods to prevent misconnections, including color-coding, labels and tags. However, these methods alone have not been effective because they are not consistently applied and do not physically prevent Luer misconnections^2,3.
 

¹ Clarkson, John, Langdon, Patrick, Robinson, Peter. Designing Accessible Technology. Springer-Verlag London Limited, 2006. Print.
² Tubing Misconnections- a persistent and potentially deadly occurrence. (2006) The Joint Commission Sentinel Event Alert Issue 36
³ Purple is not an official standard for either enteral or PICC lines. (2009) ISMP Medication Safety Alert Volume 14 Issue 11