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Tubing misconnections is an unfortunate and rare occurrence in intensive care units, but the complication is grossly underreported as it is often attributed to human error rather than device failure. This potential underreporting of a complication causes concern because it can be prevented by making an appropriate device design and increase awareness among health care workers. In this case report, we have discussed an enteral feed misconnection to an intravenous cannula has led to respiratory distress and acute kidney injury in a patient admitted to the postoperative intensive care unit. We propose a standard operating protocol for management in such a scenario and the role of ventilation-perfusion (V/Q) scan as an alternative to conventional computed tomography pulmonary angiogram (CTPA) in acute kidney injury patients.

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