Pa Patient Saf Advis 2018 Jun;15(2).
Safety Stories

‚ÄčThis vignette presents a brief, timely highlight of an event reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.

The Luer Lock That Wouldn't

Event*

Facility staff found that the Luer lock connection on a medical device did not stay engaged. Staff removed all stock from service and notified the manufacturer. Facility resumed use of the previously utilized product, and provided samples of both products to the manufacturer.

Opportunity

When possible, facilities are urged to consider an engineering solution in preference to staff training as a method to manage a problematic mechanical system.

_________

* The details of the PA-PSRS event narrative in this article have been modified to preserve confidentiality.

PSA LOGO

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at http://patientsafety.pa.gov.

©2018 Pennsylvania Patient Safety Authority