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Enteral Feeding Misconnections in the NICU: A Continuing Patient Safety Threat

Staebler, Suzanne DNP, APRN, NNP-BC

doi: 10.1097/ANC.0000000000000032
Professional Growth and Development

Although the first case of tubing misconnection was reported in 1972, this patient safety issue received little national attention until The Joint Commission issued a Sentinel Event Alert in the spring of 2006. This was followed by a “Money and Policy” article in the New York Times in the summer of 2010 that initiated a public awareness outcry against the healthcare system's delayed responsiveness in creating fail safe solutions.1 Since that time, many manufacturers have devised oral syringes, feeding tubes, and feeding “systems” for patients in the neonatal intensive care unit, but these devices' ability to minimize risk is not well delineated. This article reviews the history of tubing misconnections and provides an in-depth look at current recommendations for manufacturing and device design, human factors contributing to misconnections, and specific strategies for minimizing patient safety risk.

Pediatrix Medical Group of Tennessee, Nashville.

Correspondence: Suzanne Staebler, DNP, APRN, NNP-BC, 1613 Clearview Dr, Brentwood, TN 37027 (

The author acknowledges a previous consulting relationship with NeoChild, LLC and current consulting relationships with: Alliance for Patient Access, York's Medical and Melnic Consulting.

The author declares no conflict of interest.

© 2013 by The National Association of Neonatal Nurses