Tube Feeding Error: Fatal Medical Mistakes

Main Category: Medical Practice Management
Article Date: 16 Jul 2009 - 2:00 PDT

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The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), whose mission is to improve patient care by advancing the science and practice of nutrition support therapy, is saddened by the recent death of an infant in Madrid, Spain, who died when formula was given to him through an IV catheter and not through a feeding tube in his stomach.

"This type of tube feeding error, or enteral misconnection, is preventable," said Peggi Guenter, PhD, RN, CNSN, director of clinical practice, advocacy, and research affairs for A.S.P.E.N. "Best practices in EN require a comprehensive understanding by healthcare practitioners and changes to clinical and organizational processes. That's why A.S.P.E.N. works every day to provide research, training and guidelines and standards so that healthcare professionals have the knowledge they need to prevent these deadly mistakes."

Patients receiving enteral nutrition, sometimes referred to as "tube feeding," are unable to feed themselves and are frequently among the most critically ill. EN is the delivery of food directly into the gastrointestinal tract (GI) through a tube placed in the nose, the stomach or the small intestines. These patients often have many other types of tubes such as IVs, oxygen, or drainage tubes in them.

It's not the first time an enteral misconnection has caused a death; the first one was reported in 1973. In addition to this week's incident in Madrid, A.S.P.E.N. staff recently learned about the case of a young pregnant woman who was erroneously given tube feeding formula into her IV line, resulting in the death of her 35-week fetus, and shortly thereafter, her death.

A.S.P.E.N. is at the forefront of providing guidelines and standards, position papers and scientific articles, as well as creating industry dialogue on this topic. One key issue is to establish design standards for an enteral connector so that they are not compatible with connectors from other medical devices such as IVs, neuroaxial devices, breathing systems, or blood pressure cuffs. These standards redesign take years to develop and implement but the concern is great about medical misconnections and the change process has begun.

The Enteral Nutrition Practice Recommendations. This recently released document covers ordering and labeling of enteral nutrition; enteral formula (medical foods) and infant formula regulation; water and enteral formula safety and stability; enteral nutrition administration and more.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is dedicated to improving patient care by advancing the science and practice of nutrition support therapy. Founded in 1976, A.S.P.E.N. is an interdisciplinary organization whose members are involved in the provision of clinical nutrition therapies, including parenteral and enteral nutrition. With more than 5,500 members from around the world, A.S.P.E.N. is a community of dietitians, nurses, pharmacists, physicians, scientists, students and other health professionals from every facet of nutrition support clinical practice, research and education.

Source: The American Society for Parenteral and Enteral Nutrition

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