Spooky lure lock stories!

[Antikigirl, ASN, RN]

I was discussing with my charge nurse about this wonderful site, and how helpful it is to communicate with other nurses, and exchange ideas and stories. She was interested, and then showed me a paper the admin had given out about lure lock mistakes...OH MY! It really spooked me and opened my eyes to something I never really thought about!

Check this out...many tubes with lure lock systems for your IV's also fit the tubes for BP cuffs, Air Boots/SCD's, G or J Tubes, wound vacs, and such. I thought about ours and it is totally true! Also most syringes!!!

Now here is the catch. I read three stories, and each was about a mistake of hooking one of these on a different line not suppose to be there!

1. A nurse was called to a emergency, and left a medication to be given orally but in a syringe for an infant in the room, the mother...wanting to be helpful gave it to the baby in the central line the baby had. Baby died.

2. A family member to a patient in order to be helpful accidentally hooked an air boot line to the pts G-tube port that was dangling and not being used at the time. (pt saw tube thought something must go in there!). Machine was on, pt died (coded) on the way to OR to be worked on for this.

3. A disposable BP cuff was under a patient with the tube sticking out, a helpful CNA accidentally thought she popped off a line to the central line and hooked that tube to it. Sadly the port was open and the pt got a huge air boluses when they turned or moved. Pt coded and died.

WOW...I just never thought about this happening because I check my tubes very carefully from point of entry back...and wind up untangling pts while I am doing it. But boy...you better check them more frequently incase someone you didn't know would touch them or even dare to hook them up did!!!!!! EEEEEEEEKKKKKKKKKKK!!!!!!!!!

Even when I am the visitor to my loved ones in the hospital I do not touch the equipment (except maybe a beeping IV saying done or occlusion..then I can fix that and call the RN)...I do not attach things...don't mess with settings...NOTHING! It scares me that others that don't know would...even if trying to be helpful to the RN. SCARY!!!!!!!!!

I will be certainly checking my ports every time a pts family comes in..LOL!

[sister--*]

It seems to me that I've heard about this and have thought how frightening!

Because of this our facility does not allow any oral or topical meds to be administered using a leur lock syringe. In addition, we are also supposed to label each line and follow it from body to end or end attachment. It works well with patients with few lines. However, get many, many lines and it all is such a confusing mess.

Thanks for the reminder to always, always, always identify lines before use!

[mamason]

Wow..Never heard of that happening before. Very.....Scary!