Our July 10, 2007 Tip of the Week ďCatheter Connection Errors/Wrong Route ErrorsĒ focused on catheter misconnections and we continued to see more patient deaths from Luer misconnections in our November 2007 Whatís New in the Patient Safety World column.
The October 2007 issue of FDA Patient Safety News highlighted continued deaths from Luer misconnections and cited an excellent summary article by Gallauresi, Eakle, and Morrison in Safe Practices in Patient Care. It includes the history of the Luer connector, multiple real examples of misconnections, and the state of the industry in its attempts to develop standards to avoid this serious problem. It reiterates the recommendations of the 2006 Joint Commission Sentinel Event Alert on this issue.
Now another unfortunate case has occurred in Spain. A woman who was Spainís first fatal case of the swine flu gave birth to a premature infant, who apparently was doing well until the event occurred.† Then, his tube feeds were erroneously given via the intravenous route, resulting in death of the infant.
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) also recently learned about the case of a young pregnant woman who was erroneously given tube feeding formula into her IV line, resulting in the death of her 35-week fetus, and shortly thereafter, her death. The A.S.P.E.N. press release above also has links to new resources on avoiding such misconnections.
Medical error ends the life of premature baby of Dalilah Mimouni first of Spainís swine flu deaths
Tube Feeding Error: Fatal Medical Mistakes