New ISMP LTC AdvisERR Issue Describes New Enteral Connectors

April 21, 2015    |   By: Calevir

Twenty-five years ago, I was involved in the investigation and response to a patient’s death that occurred because a really good nurse accidentally administered tube feeding into the patient’s IV.   At the time, we looked in vain for a foolproof connector system to prevent any future similar mistakes.
Recently, new standards have been driving the development of connectors  for enteral (tube feeding) systems that are incompatible with other connectors.   The latest edition of LTC AdvisERR from the Institute for Safe Medical Practices (available here) has an extensive description of one of these systems, with comprehensive information on its benefit.   In safety science we look at establishing barriers that keep our caregivers from making inevitable human errors.   This design and the recommendations behind this represent a true step forward for the science of safety.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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