Case 1: Two patients were to receive intrathecal methotrexate with fluoroscopic guidance, Patient A in the morning and Patient B in the afternoon. The pharmacist dispensed the two methotrexate doses and the syringe for Patient A was delivered to his ward that morning. However, the syringe was not delivered before Patient A was transported to radiology. When Patient A arrived in the radiology suite, the technician called over to pharmacy looking for Patient A’s medication. In the pharmacy, the tech saw a single syringe labeled for intrathecal use and delivered it to radiology.
Supply of the new ENFit connectors, designed to increase patient safety by preventing accidental connection of enteral feeding solutions and medications to intravenous lines, continues to improve. Some hospitals, having identified reliable supply of all the devices needed for safe patient care, have switched over to the ENFit connector.
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Responding to concerns that feeding solutions and epidural local anesthetic solutions were potentially fatal when inadvertently administered intravenously, California passed a law establishing deadlines for the adoption of different connectors for these different applications.
There have been recent important developments in deployment of the new, safer, enteral connectors. As of January 2016, California law prohibits hospitals and skilled nursing facilities from using enteral feeding connectors that would fit into other types of connectors (e.g., intravenous), unless an emergency or urgent situation exists and the prohibition would impair the ability to provide health care.
A typical patient can be connected to several devices to receive medications, fluids and nutrients. Unfortunately, these tubes can be misconnected. One example of a dangerous misconnection is when a patient received enteral feeding formula intravenously because the tubing intended for the feeding tube was connected to the IV instead. Organizations have tried different strategies to reduce the risk of these misconnections.
The Association for the Advancement of Medical Instrumentation (AAMI) has a set of resources related to the risk of small bore connector misconnections. Luer connectors are used for varied applications, some of which are fundamentally dangerous if used in the wrong context. For example, and inflator for a blood pressure cuff can rapidly produce a fatal air embolus if misconnected to an IV line instead.