The lingering safety menace: a 10-year review of enteral misconnection adverse events and narrative review. August 28, 2024

https://psnet.ahrq.gov/issue/lingering-safety-menace-10-year-review-enteral-misconnection-adverse-events-and-narrative The lingering safety menace: a 10-year review of enteral misconnection adverse events and narrative review. Ethington S, Volpe A, Guenter P, et al. Nutr Clin Prac. 2024;Epub Jul 18. Despite organizational guidelines, federal reports, and equipment redesign, tubing misconnections continue to occur. This review updates the 2011 article, Tubing misconnections: normalization of deviance, with a further 96 case reports of errors resulting from tubing misconnections. Harm was reported in 69% of cases and death was reported in 4% of cases. The authors urge all healthcare organizations to transition from universal connectors to syringes and tubing designed to be compatible only with themselves (for example, use of enteral tube with a unique connector that cannot be connected to an intravenous syringe).