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Nutrition in Clinical Practice
http://ncp.sagepub.com
Enteral Feeding Misconnections: An Update
Peggi Guenter, Rodney W. Hicks and Debora Simmons
Nutr Clin Pract 2009; 24; 325
DOI: 10.1177/0884533609335174
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http://ncp.sagepub.com/cgi/content/abstract/24/3/325
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The American Society for Parenteral & Enteral Nutrition
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Invited Review Nutrition in Clinical Practice
Volume 24 Number 3
June/July 2009 325-334
Enteral Feeding Misconnections: © 2009 American Society for
Parenteral and Enteral Nutrition
10.1177/0884533609335174
An Update http://ncp.sagepub.com
hosted at
http://online.sagepub.com
1
Peggi Guenter, PhD, RN, CNSN ; Rodney W. Hicks, PhD, MSN,
2 3
MPA, ARNP ; and Debora Simmons, MSN, RN, CCRN, CCNS
Financial disclosure: none declared.
Enteral misconnections are defined as inadvertent connections areas: (1) education, awareness, and human factors; (2) purchas-
between enteral feeding systems and nonenteral systems such as ing strategies; and (3) design changes. Updates on safety innova-
intravascular lines, peritoneal dialysis catheters, tracheostomy tions and programs are presented. (Nutr Clin Pract. 2009;24:
tube cuffs, medical gas tubing, and so on. Sentinel event data and 325-334)
causative factors are outlined along with potential solutions to
prevent such medical errors. The solutions can be grouped into 3 Keywords: enteral nutrition; safety
he definition of medical misconnections includes between an enteral feeding system and a nonenteral sys-
seemingly apparent incompatible systems that, tem such as an intravascular line, peritoneal dialysis
Twhen inadvertently connected, can result in life- catheter, tracheostomy tube cuff, medical gas tubing, and
1
threatening events in the clinical arena. Examples include so forth. In each case, serious patient harm, including
connections between enteral feeding tubes and intrave- death, can occur if fluids, medications, or nutrition for-
nous (IV) lines, pneumatic blood pressure tubing with IV mulas intended for administration into the GI tract are
lines, or IV lines with tracheostomy cuffs. This issue is of administered via the wrong route (eg, into the intravascu-
4
such importance that among The Joint Commission’s lar system).
proposed 2009 National Patient Safety Goals are stand- The report of inadvertent IV administration of milk in
ards that stress processes to prevent such catheter and 1972 is one of the earliest publications of an enteral mis-
5
tubing misconnections. These 2009 proposed goals connection. In 1971, a young man with a duodenal ulcer
include the following: that the organization implement a exacerbation was receiving intragastric feedings of pasteur-
standardized approach to hand off communications, ized milk. He received about 100 mL of the feeding before
including an opportunity to ask and respond to questions; it was discovered that it was infusing intravenously. He
improving the safety of using medications; labeling all developed a hypersensitivity reaction, was treated, and sur-
medications, medication containers (eg, syringes, medi- vived. The authors concluded in this 1972 report that the
cine cups, basins), or other solutions on and off the ster- intragastric “milk” drip must be named (ordered) in full
ile field; and accurately and completely reconciling and that this is especially important now with parenteral
2
medications across the continuum of care. fat emulsion in use, which resembles milk in appearance.
Enteral nutrition (EN) is nutrition provided through One published literature review found more than 60
6
the gastrointestinal (GI) tract via a tube, catheter, or citations on enteral misconnections. Published reports
3
stoma to deliver nutrients distal to the oral cavity. This consistently substantiate the severity of this type of error,
article focuses on those misconnections related to EN which, too frequently, results in the death of the patient
systems, specifically enteral misconnections. An enteral because of ensuing embolus or sepsis. As with other vol-
misconnection is defined as an inadvertent connection untary adverse event reporting systems, enteral miscon-
nections may be greatly underreported as compared to
1 the number of actual cases.
From the American Society for Parenteral and Enteral Nutrition,
2
Silver Spring, Maryland; Anita Thigpen Perry School of Nursing,
Texas Tech University Health Sciences Center, Lubbock, Texas;
and 3University of Texas, Houston. Evidence of Misconnections
Address correspondence to: Peggi Guenter, PhD, RN, CNSN, A number of leading public and nonprofit organizations
American Society for Parenteral and Enteral Nutrition (ie, United States Pharmacopeia [USP]; Emergency Care
(A.S.P.E.N.), 8630 Fenton St. Suite 412, Silver Spring, MD
20910; e-mail: peggig@aspen.nutr.org. Research Institute, now known as ECRI Institute [ECRI];
325
Downloaded from http://ncp.sagepub.com by Peggi Guenter on June 17, 2009
326 Nutrition in Clinical Practice / Vol. 24, No. 3, June/July 2009
Figure 1. Timeline of enteral misconnections and alerts.
IV, intravenous; ECRI, ECRI Institute (formerly the Emergency Care Research Institute); UK, United Kingdom; AAMI, Association
for the Advancement of Medical Instrumentation; FDA, U.S. Food and Drug Administration; ISMP, Institute for Safe Medication
Practices; JCAHO, The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations)
Institute for Safe Medication Practices [ISMP]; U.S. of misconnections. The alert was in response to 33 docu-
Food and Drug Administration [FDA]) have issued safety mented safety incidents involving oral liquids given intra-
warnings that address the potential and actual risk from venously in an 18-month period in 2005-2006. They also
medical tubing misconnections (see Figure 1 for a time- reported 3 patient deaths from this type of error between
7
line of reported misconnections and alerts). Despite 2001 and 2006.
warnings that date back to 1986, the number of case In March 2007, a review of the USP MEDMARX and
reports continues to accumulate. The Joint Commission the USP-ISMP Medication Errors Reporting (MER)
issued a Sentinel Event Alert regarding tubing miscon- Program, 2 nationally recognized voluntary medication
1
nections in April 2006. The alert stated that multiple error reporting systems, specifically identified cases involv-
4
reports to patient safety organizations, including The ing enteral feeding systems. Between January 1, 2000,
Joint Commission, ECRI Institute, FDA, the ISMP, and and December 31, 2006, the reviewers found 24 reported
USP, indicated that these misconnection errors contin- incidents involving enteral feeding formulas, other solu-
ued to occur with significant frequency and, in a number tions, or medications intended for the feeding tube but
of instances, resulted in deadly consequences. administered via the wrong route. Of those 24 incidents,
In early 2006, the FDA and American Society for 8 (33%) resulted in sentinel events (permanent injury, life-
Parenteral and Enteral Nutrition (A.S.P.E.N.) developed threatening situation, and/or death). Although the abso-
a survey to help understand the issues associated with lute number of reported cases is not large, the level of
enteral connectors and safety. The FDA’s Center for severity associated with the error was critical. Many of the
Devices and Radiological Health sent this survey to hos- cases resulted from the use of an IV syringe to dispense,
pitals in its MedSun network, and A.S.P.E.N. sent it to its prepare, or administer an enteral medication and then
members. There were 182 clinicians (including nurses, inadvertently attaching the syringe to the IV system,
dietitians, pharmacists, physicians, safety officers, and resulting in a wrong route error. These 24 cases represent
quality improvement coordinators) who responded to the several factors that can lead to wrong route errors. This
survey. When asked if their institution had experienced an categorization of the failure factors illustrates the risks of
4
enteral misconnection incident, 16.1% reported affirma- present EN delivery systems (Table 1).
tively, 57.8% reported negatively, and 26.1% reported that
they did not know. Because of patient confidentiality History of Attempts to
issues, this survey did not ask about case details from
those who reported in the affirmative. More than 30% of Eliminate Misconnections
the respondents did report that they used Luer connec-
tors (a prime connector for IV systems) in at least some In 1996, the Association for the Advancement of Medical
of their enteral systems, and 20% used additional exten- Instrumentation (AAMI) Infusion Device Committee
4
sion tubing with Luer connectors. convened an expert group to address the safety require-
In early 2007, the British National Health Service ments for enteral feeding set connectors and adaptors.
issued a National Public Safety Alert regarding the risks This expert group included members from the FDA,
Downloaded from http://ncp.sagepub.com by Peggi Guenter on June 17, 2009
Enteral Feeding Misconnections / Guenter et al 327
Table 1. Reported Enteral Misconnections and Related Factors (January 2000–December 2006)
Percentage of Cases With
Sentinel Events (Life
Related Factors Number of Cases Number of Sentinels Events Threatening or Fatal)
Use of syringe pump and intrave- 1 0 0
nous (IV) tubing
Use of ready-to-hang enteral con- 3 2 66
tainers/bags and IV tubing
Enteral medications administered 13 3 23
intravenously (used IV syringe)
Other solution intended for enteral 4 2 50
route given intravenously
Enteral tube not in place, meds 3 1 33
given intravenously
Total 24 8 33
Data supplied by USP MEDMARX and USP-ISMP Medication Errors Reporting Program. Reprinted with permission from Guenter
P, Hicks RW, Simmons D, et al. Enteral feeding misconnections: a consortium position statement. Jt Comm J Qual Patient Saf.
2008;34:285-292.
A.S.P.E.N., various safety organizations such as the ECRI of prefilled, closed-system formula bags or containers, an
Institute, and manufacturers of feeding sets. The result- enteral administration set must be spiked into the bag,
ing voluntary standard, approved in 1996 and reaffirmed making it a 2-piece enteral set (Figure 3). The distal end
in 2005, recommended that adapters and connectors of the enteral set connector attaches to the proximal end
used in the enteral system should be incompatible with of the feeding tube. Some feeding tubes contain only 1
8
female Luer-Lok rigid connectors. port; that is, this single-lumen tube does not have a side
A British Standards document describes the step con- port for medication administration. Often, clinicians
nector (often referred to as a “Christmas tree” connector) attach adaptive devices, such as Luer-Lok stopcocks or
9
as being an alternative connector design. Many manu- extension tubing sets, between the feeding set and the
facturers developed feeding sets with these step connec- feeding tube. These devices facilitate flushing and medi-
tors so that the feeding sets were incompatible with Luer cation administration (Figures 2 and 3). The general
connectors on IV lines. Following release of the AAMI practice is to change the enteral feeding set daily, which
standard, more manufacturers adopted this design. results in an interruption of the feedings. There are also
Unfortunately, these standards are voluntary, lack pre- a number of other reasons to interrupt or discontinue
scriptive direction, and are not universally followed by all feedings, including patient testing, intermittent feedings,
device manufacturers, and thus connectors still remain a patient intolerance, and for flushing and medication
serious hazard to patients. administration when the tube does not have side ports
Currently, AAMI has convened a working group to and the main port is in use for feeding.
first set standards for small-bore connectors. Once that is The system used to provide enteral feedings in some
complete, a specific enteral connectors working group pediatric and nearly all neonatal patients differs from the
will convene. Each working group is made up of industry, system described above. In infants, small-volume feedings
association, and academic experts. require low infusion rates. This has been accomplished by
using syringes with IV syringe pumps rather than adult-
size feeding sets and pumps. Some care settings use spe-
Enteral Feeding System cially tipped oral syringes for enteral delivery of formula,
11,12
breast milk, and oral medications. Oral syringes or
The enteral feeding system for adults and older children dispensers are syringe-like devices with a unique tip con-
is the entire apparatus from the EN formula container to figuration that cannot accommodate a hypodermic needle
the delivery tubing to the enteral tube itself. The system or actuate a needleless IV access port (Baxa Corporation,
includes all connectors, pumps, or syringes that may Englewood, CO). The infusion devices (eg, syringe
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come into connection with the system. The enteral feed- pumps), until recently, were only calibrated for use with
ing set is the feeding container or bag attached to the parenteral syringes. In addition, the design of most infant
delivery tubing, which ends with a connector. This feed- feeding tubes allowed the tubing to accept Luer-Slip or
ing set may be a 1-piece device with the container con- Luer-Lok connectors for compatibility with parenteral
12,13
nected permanently to the tubing (Figure 2). In the case syringes.
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