Tube-feeding errors targeted for reduction
Tube-feeding misconnections fall into the category of medical errors that are so obviously wrong that clinicians think they could never make such a mistake. But feeding tube errors do happen, and they sometimes bring grave consequences.
A new program is designed to educate clinicians about how to avoid such errors. The Be ALERT initiative, sponsored by Nestle and the American Society for Parenteral and Enteral Nutrition (ASPEN), was launched in February. Be ALERT is designed to reduce the risk of tube-feeding misconnections in hospitals and clinics and educates caregivers about the key steps to take at the bedside when administering a tube feeding. The initiative also complements ASPEN's new Enteral Nutrition Practice Recommendations, a set of guidelines designed to increase overall patient safety by mitigating adverse events related to enteral nutrition (or tube feeding).
The Be ALERT system addresses an age-old patient safety issue, says Ainsley Malone, MS, RD, LD, CNSD, a nutrition support dietitian at Mount Carmel Health System in Columbus, OH, and a board member with ASPEN.
"I've been in practice for 25 years, and I can remember 20 years ago hearing about a patient who had an IV line connected to their enteral feeding, and it's exciting that there is finally some recognition of this problem even though it has been occurring for many, many years," Malone says. "I don't think the reporting is as rigorous as it should be, so we don't recognize how much this problem occurs."
More than 300 people died or suffered serious injury from tubing misconnections between 2000 and 2004, according to information provided by ASPEN. Malone says she suspects the actual number of misconnections is much higher than the number of reported cases.
The "ALERT" letters of the Be ALERT program stand for the key steps in avoiding enteral misconnections:
Aseptic technique;
Label enteral equipment;
Elevate head of bed;
Right patient, formula, and tube;
Trace all lines and tubing back to patient. Those are the main methods by which clinicians can ensure tubes are connected properly, Malone says. (Editor's note: A poster provided by ASPEN that is used to educate clinicians about the Be ALERT steps can be downloaded at www.nutritioncare.org/WorkArea/show content.aspx?id=2968. The Enteral Nutrition Practice Recommendations are available online at www.nutritioncare.org/WorkArea/showcontent.aspx?id=3128. More information about Be ALERT is available at the ASPEN web site, www.nutritioncare.org.)
Bundle tube with feeding container
Selection of the right feeding tube equipment also is important, Malone says. Malone's facility is a 500-bed academic teaching hospital, and she is involved with the evaluation and purchase of new devices used for enteral feeding. The hospital is in the process of changing over to a new enteral feeding formulary, and part of that changeover will include introducing all clinicians to the Be ALERT initiative.
"Clinicians have to be educated about this, because they think it can never happen to them. You ask nurses about feeding tube misconnections and they say, 'That's crazy. I would never do that,'" Malone says. "They recognize that IV and enteral feeding tubes are incompatible, but when they are in a situation where things are hectic, a nurse is tired, or something is not normal that day, that's when these errors can occur. Every nurse is trained not to make this mistake, but when you trace the root causes back, you find factors like working double shifts that prohibit you from working at your normal level of safety."
Be ALERT is a reminder
The Be ALERT system is intended to serve as a reminder to clinicians that tube misconnections can happen and that the risk can be greatly reduced by following a standard pattern of behavior at the bedside. Many institutions post the Be ALERT steps in the patient's room, often right on the enteral feeding pump.
Malone notes that many institutions are moving toward a policy of providing the right feeding tube along with the enteral feeding container as a way of ensuring that the right tube is used. Her facility now provides clinicians with an enteral feeding set that includes the correct tubing, rather than providing only the feeding container and leaving the nurse responsible for connecting the correct tubing.
"We actually rubber band the tubing to the feeding container and deliver it as a set, so that the nurse knows that is exactly the tubing to use to connect to the feeding container," she says. "It's a way to eliminate or at least reduce the risk from one step in the process."
Numerous safety organizations and advocates have called for manufacturers of medical products to minimize misconnection risk in the design of their products.
Reduce number of patients with tubes
Tube-feeding errors can be significantly reduced with attention to the process, says David J. Pagano, RN, vice president of clinical operations at Trinity Senior Living Communities in Livonia, MI. He notes that long-term care facilities have an advantage over many other health care providers on this issue, because their patients typically are in the facility long term, with standing orders for tube feeding and clinicians who are highly experienced with this task and perhaps less distracted than those working in other settings.
"The episodes of feeding-tube errors in this industry are very low just because of some of the unique factors in long-term care," he says. "Secondly, this industry is very highly regulated, with oversight from a number of agencies and regulators. As an industry, we are so regulated with tube feeding that it's an issue that has always been a top concern."
The error rate also is lower with gastric tubes, which are the only method found in long-term care, rather than the nasogastric feeding seen more often in hospitals, Pagano says.
"Part of our low error rate is the nature of long-term care, but I also think that over the past decade, we have really smartened up about tube feeding, with registered dietitians who are fully involved with tube feeding," Pagano says.
Another way to reduce the risk of feeding-tube errors is to reduce the number of patients with feeding tubes, Pagano says. The national average for long-term care patients on feeding tubes is about 7.5%, he says, but Trinity's figure is only 2.5%.
"One way to avoid feeding-tube errors is to make sure they are only on the feeding tube if they truly need it, so we put a lot of effort into making sure no one is on it that doesn't really need to be," Pagano says. "There also is the issue of quality of life, which is so much better without a feeding tube, so we evaluate all of our residents on feeding tubes at least four times a year to make sure they still need to be on it."
Sources
For more information on reducing feeding tube errors, contact:
Ainsley Malone, MS, RD, LD, CNSD, Nutrition Support Dietitian, Mount Carmel Health System, Columbus, OH. Telephone: (614) 855-1002. E-mail: [email protected].
David J. Pagano, RN, Vice President, Clinical Operations, Trinity Senior Living Communities, Livonia, MI. Telephone: (734) 542-8342. E-mail: [email protected].
Tube-feeding misconnections fall into the category of medical errors that are so obviously wrong that clinicians think they could never make such a mistake. But feeding tube errors do happen, and they sometimes bring grave consequences.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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