The lingering safety menace: A 10-year review of enteral misconnection adverse events and narrative review.

Autor: Ethington S; Nursing Professional Practice and Development, Nebraska Medicine, Omaha, Nebraska, USA., Volpe A; Hartford HealthCare, Hartford, Connecticut, USA., Guenter P; American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA., Simmons D; McWilliams School of Biomedical Informatics, UTHealth Houston, Houston, Texas, USA.
Jazyk: angličtina
Zdroj: Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition [Nutr Clin Pract] 2024 Oct; Vol. 39 (5), pp. 1251-1258. Date of Electronic Publication: 2024 Jul 18.
DOI: 10.1002/ncp.11191
Abstrakt: In 2011, "Tubing Misconnections: Normalization of Deviance" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.
(© 2024 American Society for Parenteral and Enteral Nutrition.)
Databáze: MEDLINE
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