Tubing and Luer Misconnections: Preventing Dangerous Medical Errors

Patients in health care settings receive medications and other therapies through a variety of tubes and catheters. These delivery systems often use parts called small-bore connectors to link various components. Small-bore refers to the small size of the opening of the connector. Luer connectors are a commonly used type of small-bore connector and throughout this website the term Luer will be used to describe both Luer and other types of small-bore connectors.

Because these connectors are compatible between different delivery systems, patient injuries and deaths have occurred when medicines, liquid feeding formulas, or air were accidentally delivered through the wrong tubing. These errors are sometimes called tubing misconnections, wrong route errors, catheter misconnections or Luer misconnections. It is vitally important that all health care clinicians receive appropriate orientation and training that emphasizes the risk of tubing misconnections. This includes not only acute care settings, but, long-term care, rehabilitation facilities, home health care, physician offices, and any non-clinical settings in which a small-bore connector may be used on a patient.

This website explains how misconnections occur, provides real-life examples of misconnections, and offers tips and additional resources for preventing them. Guidance for manufacturers of enteral feeding systems is also provided.

Luer Lock (left) and Luer Slip (right)
Photo Courtesy of Beaumont Hospitals