Nutr Clin Pract. 2025 Aug 10. doi: 10.1002/ncp.70003. Online ahead of print.
ABSTRACT
The safe use of enteral nutrition (EN) for patients of all ages in the healthcare setting is often taken for granted. However, an increasing body of literature highlights potential failure points even when using ready-to-feed (RTF) enteral formulas. Potential risks include administering a wrong, expired, or recalled formula which could result in patient harm including under or over nutrition, allergic reactions, gastrointestinal intolerance, metabolic or electrolyte disturbances, and/or consequences related to contamination. This quality improvement project reviewed the frequency of having the wrong RTF EN formula scanned for the wrong individual (defined as a near miss) in pediatric patients 1-18 years of age. During the time of this evaluation, a total of 48,044 RTF EN formula feeding attempts were recorded. Of those attempts, 46,648 were successful, with the RTF EN formula matching the patient’s EN order when the patient’s armband and EN bar code were scanned. The remaining 1396 attempts represented near misses in which the product being scanned was not the correct product for the patient (a rate of 2.9%). Although this rate may seem low, the number of near misses during this time frame means that, on average, 48 times per month or 1.6 times per day, the bar code scanning system is preventing a pediatric patient from receiving the wrong EN formula. The data from this performance improvement initiative support the organization’s decision to scan EN formulas at the time of administration and underscores the importance of following protocols to ensure that scanning occurs every time when administering formulas to reduce risk of error.
PMID:40783803 | DOI:10.1002/ncp.70003
