Misconnections between enteral devices and other devices (e.g.,
IV), while rare, can have catastrophic consequences. In
recognition of this, California has a law prohibiting 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.
This White Paper is a translated and edited version of a
guideline document drafted by the German Coalition for Patient
Safety (Aktionsbündnis Patientensicherheit/APS). It contains
guidelines intended for all parties involved with the complex
changeover to ISO 80369 connectors and it aims to contribute to
patient safety across the different healthcare applications.
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
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.
Please fill out a
brief CHPSO survey so that we can gather current information
on the status of adoption in California and identify where
assistance is needed.
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
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.