Reduce and Report Enteral Feeding Tube Misconnections
MedSun: Newsletter #55, December 2010

FDA Medical Device Safety

Enteral feeding tubes that are mistakenly connected to other applications may result in patient death or injury, as is widely known within the healthcare community. But in the last four years, only a few of these adverse events were reported to the FDA. Misconnections of enteral devices may be underreported because connecting feeding tubes to the wrong tubing, such as an I.V. or dialysis catheter, is often attributed to human error rather than device failure. This potential underreporting causes concern because the risk of enteral feeding tube misconnections could be further reduced by incorporating human factors assessment into device design. For these reasons, all adverse events and “near misses” should be reported to the FDA, whether they’re considered device or human error.

Additional Information:

FDA Medical Device Safety. Reduce and Report Enteral Feeding Tube Misconnections. November 19, 2010.
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm234440.htm