1Texas Woman’s University, Houston, Texas 77030, USA.
Nutr Clin Pract. 2011 Jun;26(3):286-93. doi: 10.1177/0884533611406134.
Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible systems.
The purpose of this review of case studies of tubing misconnections and of current expert recommendations for safe tubing connections was to answer the following questions: In tubing connections that have the potential for misconnections between enteral and IV tubing, what are the threats to safety? What are patient outcomes following misconnections between enteral and IV tubing? What are the current recommendations for preventing misconnections between enteral and IV tubing? Following an extensive literature search and guided by 2 models of threats and errors, the authors analyzed case studies and expert opinions to identify technical, organizational, and human errors; patient-related threats; patient outcomes; and recommendations.
A total of 116 case studies were found in 34 publications. Each involved misconnections of tubes carrying feedings, intended for enteral routes, to IV lines. Overwhelmingly, the recommendations were for redesign to eliminate universal connectors and prevent misconnections. Other recommendations were made, but the analysis indicates they would not prevent all misconnections.
This review of the published case studies and current expert recommendations supports a redesign of connectors to ensure incompatibility between enteral and IV systems. Despite the cumulative evidence, little progress has been made to safeguard patients from tubing misconnections.
肠内系统意外连接到静脉（IV）系统通常会导致患者死亡。连接错误通常归因于大多数患者护理管系统中存在通用连接器。通用连接器允许在生理不相容的系统之间进行管连接错误。
本研究回顾了管连接错误的案例研究以及当前安全管连接的专家建议，旨在回答以下问题：在有肠内和 IV 管之间连接错误的可能性的管连接中，存在哪些安全威胁？肠内和 IV 管之间连接错误后患者的结局如何？目前有哪些预防肠内和 IV 管之间连接错误的建议？经过广泛的文献检索，并根据威胁和错误的 2 个模型，作者分析了案例研究和专家意见，以确定技术、组织和人为错误；患者相关威胁；患者结局；和建议。
在 34 篇出版物中发现了总共 116 个案例研究。每个案例都涉及将用于肠内途径的输送管误接到 IV 线上。压倒性的建议是重新设计以消除通用连接器并防止连接错误。还提出了其他建议，但分析表明它们无法防止所有的连接错误。
对已发表的案例研究和当前专家建议的审查支持重新设计连接器，以确保肠内和 IV 系统之间不兼容。尽管有累积证据，但在保护患者免受管连接错误方面几乎没有取得进展。
