Critical Notice–Avoid Fatal Misconnections with ENFit-compliant Feeding Tube Connectors

ECRI Institute releases alert and guidance on preventing enteral tubing misconnections

April 26, 2017

PLYMOUTH MEETING, PA—When a woman checked into the hospital at 35 weeks pregnant, she never thought a misconnection would have a fatal consequence. A clinician inadvertently coupled her enteral feeding tube to a peripheral intravenous line, delivering nonsterile nutrition directly into the bloodstream, and ultimately causing death to her and her baby.

According to ECRI Institute, in a just-released alert and guidance article, the risks from misconnections of enteral feeding tubing are preventable with the use of a new connector design (right) called ENFit. Although ENFit has received some exposure, many hospitals and clinicians that manage enterally fed patients remain unaware of or unprepared for this important initiative.

ECRI Institute recommends using tubing accessories with ENFit connectors to ensure that enteral connectors will not attach to connectors used with other medical technologies. Currently mandated only in California, the new enteral connector dimensions conform to the International Organization for Standardization's ISO 80369-3 standard and ENFit is a global initiative.

"To prevent any more errors, ECRI is urging facilities to move to the new connectors as soon as practicable–ideally by the end of 2017," says Tim Ritter, CBET, CCE, senior project engineer, ECRI Institute.

The publicly available guidance article from ECRI Institute provides tips for transitioning to enteral tubing accessories with ENFit connectors.

ECRI Institute is a supporting organization of the Global Enteral Device Supplier Association (GEDSA). Other supporting organizations include the Joint Commission, National Patient Safety Foundation (NPSF), and Institute for Safe Medication Practices (ISMP). See the full list of supporting organizations on the GEDSA website.

For additional information, please contact ECRI Institute by telephone at (610) 825-6000, ext. 5310; by e-mail at; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462 USA.

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About ECRI Institute
ECRI Institute (, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs, and processes enable improved patient care. As pioneers in this science for 50 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. Strict conflict-of-interest guidelines ensure objectivity. ECRI Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute PSO is listed as a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services.

For more information, contact:
Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310