Luer Misconnections continue to result in adverse events and deaths – Luer connectors easily link many medical components,
accessories, and delivery systems. Clinicians, in any type of provider or supplier setting, can mistakenly connect the wrong
devices and deliver substances through the wrong route. Despite numerous alerts and warnings, a patient’s blood pressure tubing
was recently misconnected to an intravenous (IV) line in an ambulatory surgery center (ASC) resulting in a patient death.
• Adverse Event Complaint Investigation: During a complaint investigation for an adverse event involving delivery of an incorrect
substance or utilization of an incorrect delivery route, surveyors must be alert to whether the event involved misconnection
of a Luer device. If so, surveyors must determine whether the facility has taken actions to ensure systems are in place to
prevent recurrence of this type of adverse event.
• Facility Reporting to Food & Drug Administration (FDA): Surveyors should encourage health care facilities to report problems
with Luer misconnections to the FDA, even if no adverse event occurred.
