When a woman checked into the hospital at 35 weeks pregnant, she never thought a misconnection would have a fatal consequence. A clinician inadvertently coupled her enteral feeding tube to a peripheral intravenous line, delivering non-sterile nutrition directly into the bloodstream, and ultimately causing death to her and her baby.

According to ECRI Institute, in a just-released alert and guidance article, the risks from misconnections of enteral feeding tubing are preventable with the use of a new connector design called ENFit. Although ENFit has received some exposure, many hospitals and clinicians that manage enterally fed patients remain unaware of or unprepared for this important initiative.

ECRI Institute recommends using tubing accessories with ENFit connectors to ensure that enteral connectors will not attach to connectors used with other medical technologies. Currently mandated only in California, the new enteral connector dimensions conform to the International Organization for Standardization’s ISO 80369-3 standard and ENFit is a global initiative.

“To prevent any more errors, ECRI is urging facilities to move to the new connectors as soon as practicable–ideally by the end of 2017,” says Tim Ritter, CBET, CCE, senior project engineer, ECRI Institute.

The publicly available guidance article from ECRI Institute provides tips for transitioning to enteral tubing accessories with ENFit connectors.

ECRI Institute is a supporting organization of the Global Enteral Device Supplier Association. Other supporting organizations include the Joint Commission, the National Patient Safety Foundation, and the Institute for Safe Medication Practices.