How Tubing and Luer Misconnections Occur

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.