Avoiding Catheter Misconnections

Enteral feeding solutions have mistakenly been delivered to patients via an intravenous route, resulting in patient injury and even death. Dr. Catherine Blanchon, Operations – Supply Chain Quality Management, Nestle Nutrition, Switzerland, spoke about the risk of such misconnections at Pharmapack in 2009, urging attendees to devise solutions with their own product development.

Standards may be on the way to support safe administration. The Institute for Safe Medication Practices (ISMP) is reporting that The International Organization for Standardization (ISO) has been working on ISO/IEC/FDIS 80369-1, "Small-bore connectors for liquids and gases in healthcare applications," to make various healthcare catheter fittings and associated tubing sets or syringes incompatible with one another.

ISMP reports that "as part of the new enteral standard, a female luer connector will not be present on feeding tubes, except for the inflation balloon that anchors some long-term use feeding devices. In the past, such connectors on feeding tubes forced nurses to administer enteral feedings and liquid medications with a parenteral syringe or administration set. This, of course, made it possible for enteral substances to be accidentally connected to a luer connector on an IV system or other systems with luer connectors."

Misconnections troubles were well documented in May 2008 in "Enteral Feeding Misconnections: A Consortium Position," published in The Joint Commission Journal on Quality and Patient Safety.

And in 2007, The Medicines and Healthcare products Regulatory Agency (MHRA) issued a Patient Safety Alert imploring that enteral feeding systems, including syringes, be designed without ports or connectors that can be connected to intravenous or other parenteral lines.

Universal design improvements are still lacking, as ISMP reported that earlier this year "a 19-month-old child, who was receiving treatment for a chronic gastrointestinal disorder, died at a pediatric care center. A suspension of QUESTRAN (cholestyramine) was accidentally given via a central line intravenous catheter instead of through an enteral feeding tube."

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