Warning: Inadvertent Administration of Enteral Feed into a Peripheral Cannula

Posted on: 4th March, 2011 by the NNNG.

An incident has occurred where a member of hospital staff adapted the medicine port on an enteral feed giving set to enable it to be directly connected to a patient’s peripheral venous cannula. Unfortunately enteral feed was administered directly into the cannula before the error was identified, resulting in the patient becoming seriously ill.

The giving set used was fully NPSA compliant (see NPSA recommendation below), however it was the adaptation of the set, which allowed feed to be administered via an un-intended route.

Please highlight with your link nurses and senior nursing staff that no adaptations should be made to enteral feeding equipment and that the possibility of wrong route administration may still occur.

NPSA Recommendation 2:

Design, supply and use of enteral feeding systems.

  • Enteral feeding systems should not contain ports that can be connected to intravenous syringes or that have end connectors that can be connected to intravenous or other parenteral lines
  • Enteral feeding systems should be labelled to indicate the route of administration.
  • Three-way taps and syringe tip adaptors should not be used in enteral feeding systems because connection design safeguards can be bypassed.

Ref: NPSA (2007) Patient Safety Alert: Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.

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