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