ISMP
MEDICATION ERRORS ANN SHASTAY, MSN, RN, AOCN
New Connectors Coming for Enteral Feeding Tubes In the first quarter of 2015, the International Organization for Standardization (ISO) will introduce new design standards for enteral feeding device connectors. Introduction of the new connectors, called ENFit, is crucial to patient safety because the current Luer-type connectors have a universal design that allows connections between devices that serve completely different functions (e.g., enteral tubing connected to a tracheostomy tube inflatable cuff or an intravenous [IV] line). The new ENFit enteral connectors will be introduced by The Global Enteral Device Supplier Association (GEDSA), an international group of enteral feeding device manufacturers, distributors, and suppliers that has worked closely with the Institute for Safe Medication Practices (ISMP), The Joint Commission, the Association for the Advancement of Medical Instrumentation, the American Society for Parenteral and Enteral Nutrition, Premier Safety Institute, Novation, and the Oley Foundation, a nonprofit organization that supports those requiring home IV infusions and tube feedings. Although tubing misconnections are less of a concern in the home, the new, safer connectors will be introduced globally. So it is important to understand how the change will impact both hospital and home enteral nutrition. GEDSA has a campaign in place called Stay Connected 2014. The campaign goal is to assure that, by the time the connectors reach
228
Volume 33
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Number 4
the market, everyone who uses an enteral device will be aware of the change, be prepared to transition to the safer connector, and successfully adopt it. The new global design standards ensure that all manufacturers of feeding tubes, enteral administration sets, and enteral syringes will use one standard design for the connector that will be universally adopted into practice. The enteral-specific design does not allow connectivity with any other type of connector. It also provides a locking feature that signals the appropriate connection has been made and remains in place. It has a female connector end for administration sets and syringes that fit into a male patient-access feeding tube port. The new standards will impact syringes as well as feeding tubes and feeding administration sets. Enteralspecific syringes with the new standard female connector will be required for connection to feeding tubes with the new standard male connector in order to administer feedings or flush lines. These changes are part of a larger initiative that will later introduce standards for connectors used in other applications. The initiative is designed to reduce tubing misconnections by making sure devices for different delivery systems are not compatible. Tubing misconnections are rare, but when they occur, patient injuries can be serious, life threatening, and even fatal. Manufacturers have been working together to develop a plan for introducing the new ENFit connectors. Transition connectors or “adapters” are
planned to allow new feeding/ administration sets and syringes to connect to existing gastrostomy or jejunostomy tubes until the transition is complete. Feeding/administration sets with these adapters will start to be distributed in the first quarter of 2015. This will minimize any disruption to hospitals and consumers while allowing the use of the feeding tubes and feeding/administration sets already on hand until supplies are exhausted and the new ones are in place. Eventually, these adapters will be phased out. All major enteral device manufacturers are expected to comply with the new ISO standards. During the first quarter of 2015, customers ordering enteral administration sets will receive transition feeding/administration sets. Syringes used for flushing and boluses with the new connector and new enteral feeding tubes with an ISO standard connector will be phased in during the rest of 2015. By January 2016, the transition to new ISO standard connectors will be complete. At that point, the current universal Luer connector will no longer be available for any enteral feeding applications. Visit the Stay Connected 2014 Web site for updates (http:// www.stayconnected2014.org). ISMP wishes to acknowledge Tom Hancock, Executive Director of GEDSA, for his collaborative work on this initiative and this article.
“Patient-Friendly” Service or Danger Up Ahead Many physician practices have provided patients with drug
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
samples to get them started on a needed medication in a timely manner. Emergency departments (EDs) have also sent patients home with “starter” doses, most often in unit-dose packages of medications from the hospital pharmacy. Or, the hospital may use kiosk-type dispensing machines from outside vendors to supply the full prescription. This allows the patient to start taking the medicine as soon as possible. Dispensing samples and starter doses are often seen as “patient-friendly” services. However, the services can also have unintended consequences. The drug packages dispensed may not be child resistant. The Consumer Product Safety Commission does not require sample medications to be in child-resistant containers. Manufacturers can also request an exemption from providing child-resistant packaging for medications used only in hospitals. Thus, conventional unit-dose packages used in hospitals may not be child resistant, and a potential poisoning is possible if the medications are sent home and improperly secured. Although many EDs dispense starter doses in properly labeled, child-resistant prescription containers, ISMP has often seen starter doses dispensed in plastic bags or envelopes. Please consider that patients arriving home after a visit to the ED may not be thinking about the need to place that plastic bag or envelope up and away, and out of the reach and sight of children. Instead, these medications
April 2015
The new global design standards ensure that all manufacturers of feeding tubes, enteral administration sets, and enteral syringes will use one standard design for the connector that will be universally adopted into practice.
may be temporarily placed on a kitchen table or counter. There are other safety issues associated with dispensing drug samples and starter doses—for example, limited or absent labeling of the product with directions for use as well as the failure to monitor lot numbers and expiration dates. Although many organizations have appropriately addressed these other issues, it is still important for home care practitioners to review and educate patients and family members about the medications they are taking. Organizations that dispense drug samples or starter doses should evaluate their practices and modify their procedures as needed to ensure the safety of patients and children in their homes. With the increased availability of 24-hour community pharmacies, samples and starter-dose services may not be necessary. In either case, healthcare practitioners visiting patients in the home setting must educate patients and family members about storing medications safety. All medications should be stored up and away and out of reach from children. For more information on storing medications safely in the home setting, visit http:// www.upandaway.org
Dangerous Abbreviation “BIW” A prescription written for chlorambucil (LEUKERAN) with directions to give “one tablet BIW” (tablet strength unspecified by the reporter) led to a pharmacist typing “one tablet twice daily” when the prescriber’s intention was for the patient to take one tablet twice a week. The error was caught by a second pharmacist who did a visual check of the completed prescription prior to dispensing. Similar errors have occurred with the abbreviation “TIW” in which patients received the medication three times daily instead of the intended three times a week. Prescribers should never use these abbreviations in prescriptions—either handwritten or electronic (“BIW” and “TIW” should not be a selection for dose frequency). Both abbreviations are on the ISMP List of Error-Prone Abbreviations. Write or have electronic systems print “twice a week” or “three times a week” instead. Ann Shastay, MSN, RN, AOCN, is the Managing Editor, Institute for Safe Medication Practices, Horsham, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices, 200 Lakeside Dr., Suite 200, Horsham, PA 19044 ([email protected]). DOI:10.1097/NHH.0000000000000214
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
229
MEDICATION ERRORS ANN SHASTAY, MSN, RN, AOCN
New Connectors Coming for Enteral Feeding Tubes In the first quarter of 2015, the International Organization for Standardization (ISO) will introduce new design standards for enteral feeding device connectors. Introduction of the new connectors, called ENFit, is crucial to patient safety because the current Luer-type connectors have a universal design that allows connections between devices that serve completely different functions (e.g., enteral tubing connected to a tracheostomy tube inflatable cuff or an intravenous [IV] line). The new ENFit enteral connectors will be introduced by The Global Enteral Device Supplier Association (GEDSA), an international group of enteral feeding device manufacturers, distributors, and suppliers that has worked closely with the Institute for Safe Medication Practices (ISMP), The Joint Commission, the Association for the Advancement of Medical Instrumentation, the American Society for Parenteral and Enteral Nutrition, Premier Safety Institute, Novation, and the Oley Foundation, a nonprofit organization that supports those requiring home IV infusions and tube feedings. Although tubing misconnections are less of a concern in the home, the new, safer connectors will be introduced globally. So it is important to understand how the change will impact both hospital and home enteral nutrition. GEDSA has a campaign in place called Stay Connected 2014. The campaign goal is to assure that, by the time the connectors reach
228
Volume 33
|
Number 4
the market, everyone who uses an enteral device will be aware of the change, be prepared to transition to the safer connector, and successfully adopt it. The new global design standards ensure that all manufacturers of feeding tubes, enteral administration sets, and enteral syringes will use one standard design for the connector that will be universally adopted into practice. The enteral-specific design does not allow connectivity with any other type of connector. It also provides a locking feature that signals the appropriate connection has been made and remains in place. It has a female connector end for administration sets and syringes that fit into a male patient-access feeding tube port. The new standards will impact syringes as well as feeding tubes and feeding administration sets. Enteralspecific syringes with the new standard female connector will be required for connection to feeding tubes with the new standard male connector in order to administer feedings or flush lines. These changes are part of a larger initiative that will later introduce standards for connectors used in other applications. The initiative is designed to reduce tubing misconnections by making sure devices for different delivery systems are not compatible. Tubing misconnections are rare, but when they occur, patient injuries can be serious, life threatening, and even fatal. Manufacturers have been working together to develop a plan for introducing the new ENFit connectors. Transition connectors or “adapters” are
planned to allow new feeding/ administration sets and syringes to connect to existing gastrostomy or jejunostomy tubes until the transition is complete. Feeding/administration sets with these adapters will start to be distributed in the first quarter of 2015. This will minimize any disruption to hospitals and consumers while allowing the use of the feeding tubes and feeding/administration sets already on hand until supplies are exhausted and the new ones are in place. Eventually, these adapters will be phased out. All major enteral device manufacturers are expected to comply with the new ISO standards. During the first quarter of 2015, customers ordering enteral administration sets will receive transition feeding/administration sets. Syringes used for flushing and boluses with the new connector and new enteral feeding tubes with an ISO standard connector will be phased in during the rest of 2015. By January 2016, the transition to new ISO standard connectors will be complete. At that point, the current universal Luer connector will no longer be available for any enteral feeding applications. Visit the Stay Connected 2014 Web site for updates (http:// www.stayconnected2014.org). ISMP wishes to acknowledge Tom Hancock, Executive Director of GEDSA, for his collaborative work on this initiative and this article.
“Patient-Friendly” Service or Danger Up Ahead Many physician practices have provided patients with drug
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
samples to get them started on a needed medication in a timely manner. Emergency departments (EDs) have also sent patients home with “starter” doses, most often in unit-dose packages of medications from the hospital pharmacy. Or, the hospital may use kiosk-type dispensing machines from outside vendors to supply the full prescription. This allows the patient to start taking the medicine as soon as possible. Dispensing samples and starter doses are often seen as “patient-friendly” services. However, the services can also have unintended consequences. The drug packages dispensed may not be child resistant. The Consumer Product Safety Commission does not require sample medications to be in child-resistant containers. Manufacturers can also request an exemption from providing child-resistant packaging for medications used only in hospitals. Thus, conventional unit-dose packages used in hospitals may not be child resistant, and a potential poisoning is possible if the medications are sent home and improperly secured. Although many EDs dispense starter doses in properly labeled, child-resistant prescription containers, ISMP has often seen starter doses dispensed in plastic bags or envelopes. Please consider that patients arriving home after a visit to the ED may not be thinking about the need to place that plastic bag or envelope up and away, and out of the reach and sight of children. Instead, these medications
April 2015
The new global design standards ensure that all manufacturers of feeding tubes, enteral administration sets, and enteral syringes will use one standard design for the connector that will be universally adopted into practice.
may be temporarily placed on a kitchen table or counter. There are other safety issues associated with dispensing drug samples and starter doses—for example, limited or absent labeling of the product with directions for use as well as the failure to monitor lot numbers and expiration dates. Although many organizations have appropriately addressed these other issues, it is still important for home care practitioners to review and educate patients and family members about the medications they are taking. Organizations that dispense drug samples or starter doses should evaluate their practices and modify their procedures as needed to ensure the safety of patients and children in their homes. With the increased availability of 24-hour community pharmacies, samples and starter-dose services may not be necessary. In either case, healthcare practitioners visiting patients in the home setting must educate patients and family members about storing medications safety. All medications should be stored up and away and out of reach from children. For more information on storing medications safely in the home setting, visit http:// www.upandaway.org
Dangerous Abbreviation “BIW” A prescription written for chlorambucil (LEUKERAN) with directions to give “one tablet BIW” (tablet strength unspecified by the reporter) led to a pharmacist typing “one tablet twice daily” when the prescriber’s intention was for the patient to take one tablet twice a week. The error was caught by a second pharmacist who did a visual check of the completed prescription prior to dispensing. Similar errors have occurred with the abbreviation “TIW” in which patients received the medication three times daily instead of the intended three times a week. Prescribers should never use these abbreviations in prescriptions—either handwritten or electronic (“BIW” and “TIW” should not be a selection for dose frequency). Both abbreviations are on the ISMP List of Error-Prone Abbreviations. Write or have electronic systems print “twice a week” or “three times a week” instead. Ann Shastay, MSN, RN, AOCN, is the Managing Editor, Institute for Safe Medication Practices, Horsham, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices, 200 Lakeside Dr., Suite 200, Horsham, PA 19044 ([email protected]). DOI:10.1097/NHH.0000000000000214
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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