ISMP Targeted Medication Safety Best Practices for Hospitals 4 and 5 oral liquid medication packaging ENFit syringe conversion and use of metric scale oral liquid dosing devices mp3

June 27, 2022 Item: Conversion to enteral products (e.g., feeding tubes, adapters, syringes) with ENFit® connectors

April 26, 2021 ‐ PSQHNebraska Medicine’s ENFit Conversion Designed to Improve Patient SafetyBy Stacie Ethington, MSN, RN-BCBackgroundAdverse outcomes caused by enteral tubing misconnections are well documented in The Joint Commission’s Sentinel Event Alertfrom August 2014 that states “Tubing misconnections continue to cause severe patient injury and death.” To address the issue, in fall 2020 Nebraska Medicine converted legacy enteral tubes and disposables to be compatible with the ISO 80369-3 standard, also known as ENFit®, that is designed to prevent misconnections and disconnections.

Medical device misconnections aren’t always brought out into the news, sometimes they aren’t even correctly credited as the cause of an injury or even death.

ENFit US Conversion Rates Among U.S. News & Worlds Report Best Ranked US Hospitals

We read the article ‘Female low dose tip syringes-increased complexity of use may compromise dosing accuracy in paediatric patients’ with interest. As long-time members of the American Society of Parenteral and Enteral Nutrition and experienced nutrition support clinicians, we have some concerns we would like to share as both of our institutions are paediatric hospitals using ENFit connectors.