Although the first case of tubing misconnection was reported in 1972, this patient safety issue received little national attention until The Joint Commission issued a Sentinel Event Alert in the spring of 2006. This was followed by a “Money and Policy” article in the New York Times
in the summer of 2010 that initiated a public awareness outcry against the healthcare system's delayed responsiveness in creating fail safe solutions.1
Since that time, many manufacturers have devised oral syringes, feeding tubes, and feeding “systems” for patients in the neonatal intensive care unit, but these devices' ability to minimize risk is not well delineated. This article reviews the history of tubing misconnections and provides an in-depth look at current recommendations for manufacturing and device design, human factors contributing to misconnections, and specific strategies for minimizing patient safety risk.