Practitioners' Reporting News

Dangerous Mix Up With BP Monitor & IV Port

Issued September 30, 2003

In a recent report submitted to the USP Medication Errors Reporting Program, a patient's blood pressure monitor tubing was attached to the Y-site of a needleless IV port. If the monitor had cycled, air might have entered the patient's vascular system, creating a risk of air embolism. Fortunately, for this patient, this did not occur.

The patient was being transported to radiology, where the blood pressure cuff was disconnected to allow for appropriate positioning of the patient. When the patient returned to the unit, a family member noticed that the monitor tubing was attached to the IV tubing in the patient's arm. A nurse was notified and disconnected the tubing and reassessed the patient.

This occurred because the tubing on the blood pressure monitor's inflator had a male Luer connector that fit into a female connector on a disposable blood pressure cuff. As a result, the male connector on the blood pressure tubing also fit into the female connector on the IV port.


Mock-up picture of monitor, blood pressure cuff, & IV tubing (provided by ISMP)

According to an alert by the Institute for Safe Medication Practices (ISMP), manufacturers have issued warning letters and some manufacturers have provided warning labels for the monitors and tubing. Other manufacturers plan to require dedicated tubing with non-Luer connectors to avoid this occurrence.

Until non-Luer connectors are required, practitioners should, at a minimum, check their tubing for the potential of this dangerous connection, apply warning labels to the monitor tubing, and inform staff of this possibility. Reinforcement and education regarding the dangers associated with this type of mix up are recommended.

Web Links:
ISMP Medication Safety Alert
FDA Patient Safety News


Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.