ENFit Enteral Connectors: Avoiding Enteral Tubing Misconnections

June 30, 2017 | Special HTA Reports


In the hospital environment, numerous tubes and catheters connect medical devices to patients, but misconnections occasionally occur. Human factors (e.g., nurse fatigue, distraction, poor lighting) and physical factors (e.g., universal ports) contribute to the misconnection risk. If not recognized early, misconnections can harm patients because they can allow gases (e.g., nitrous oxide, oxygen) or liquids (e.g., solutions, medications, enteral feedings) to be introduced into the wrong lines or by unintended administration routes. Misconnections vary greatly in type (i.e., gas line, liquid line, gas and liquid line) and in the severity of their outcome.

Gas lines are commonly used for respiratory support or to power pneumatic medical equipment. Because ventilation is critical, misconnecting the lines of a breathing circuit or delivering the wrong respiratory gas can seriously injure or kill a patient. Gas misconnections that do not involve ventilation can also cause serious harm or death. For example, patient injury has resulted when pressurized gas lines, intended to pneumatically power a device, are confused with suction lines.

Liquid lines are primarily those that deliver nutrients, medications, and blood products to patients, but this category also includes other solution lines, such as flush lines. Because liquid delivery lines are often direct points of access into the body, misconnecting them can result in an appropriate substance entering the wrong body part. For example, if a liquid intended for delivery into the stomach via an enteral feeding tube is instead delivered into the bloodstream through an intravenous (IV) catheter, serious patient injury or death can result.

Gas and liquid lines can be erroneously connected. Such misconnections typically lead to severe injury, usually resulting from gas being introduced into the vasculature or liquid entering the respiratory tract. Numerous cases of respiratory gas or pressurized air lines being misconnected to patient IV lines and causing unintended gas delivery have been reported, and some have resulted in fatal air embolisms.

Misconnection risk is heightened when two functionally dissimilar devices each use Luer connectors. Luer connectors consist of male and female counterparts, or a tapered male piece that fits into a wider female fitting. While designed to easily connect medical devices, tubes, catheters, syringes, and...

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