Abstract
A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the child's stomach following surgery.
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