Preventing Misconnection Errors Medical Device Safety Calendar

FDA has received many reports of patient injuries and deaths when different device delivery systems are mistakenly connected to each other. These errors are often facilitated by fittings called Luer connectors, which allow different systems to be easily, but erroneously, connected.

The 2009 Medical Device Safety Calendar is one of FDA's efforts to help educate healthcare professionals about these dangerous misconnections. The calendar provides a graphic depiction of a variety of misconnection cases, coupled with recommendations from The Joint Commission on ways to prevent these types of errors. We hope the calendar will be posted as a year-long reminder to staff that these errors can occur in any clinical setting. We also urge clinicians to use the case synopses and recommendations as on-going training materials. They can be downloaded free of charge by going to the website. Clinical facilities may also request copies of the calendar while supplies last.




FDA Patient Safety News: April 2009

For more information, please see our website:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=85#5

Category:

Education

Tags:

• Misconnections
• medical error
• Luer connectors
• FDA
• The Joint Commission
• TJC