Enteral Feeding Misconnections: A Consortium Position Statement

Guenter, Peggi; Hicks, Rodney W.; Simmons, Debora; Crowley, Jay; Joseph, Stephanie; Croteau, Richard J.; Gosnell, Cathie; Pratt, Nancy; Vanderveen, Timothy W.

doi:10.1016/s1553-7250(08)34035-5

Cited by 47 publications

(53 citation statements)

References 12 publications

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“…Although spaghetti syndrome has been considered a serious patient care issue for many years, few studies have proposed a solution to this problem. [1][2][3]5,6,10,11,15,16 We hope that the results will reenergize the interest in solving the problem of spaghetti syndrome and lead to the development of protocols and standard processes for use of a simple solution to control entanglement of bedside tubing and wires for all hospitalized patients.…”

Section: Discussionmentioning

confidence: 99%

“…Multiple instances of patients' deaths, permanent injury, and life-threatening situations related to entanglement with the cords of medical devices have been reported. 5,[7][8][9][10][11][12][13][14] Ensuring the organization of cords and tubes at a patient's bedside may reduce adverse outcomes such as entanglement of the patient, backflow in tubing, falls by both patients and health care personnel, and connection errors or damage of medical equipment. [5][6][7]12 38 Therapeutic tubing, cables, wires, and cords are a fundamental aspect of daily health care for delivery of medications and fl uids to patients.…”

mentioning

confidence: 99%

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Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Haynes

Bowers

Young

et al. 2015

Critical Care Nurse

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Background Managing "spaghetti syndrome," the tangle of therapeutic cables, tubes, and cords at patients' bedsides, can be challenging. oBjectives To assess nurses' perceptions of the effectiveness of a novel banding device in management of spaghetti syndrome. Methods A simple color-coded elastomeric banding strap with ribbed flaps was attached to bed rails of adult critical care patients to help organize therapeutic cables, tubes, wires, and cords. Nurses were surveyed before and after use of the bands and after the nursing shift to assess the burden of spaghetti syndrome and the effectiveness of using the bands. results Use of the bands decreased the time spent untangling cords, reduced the frequency of contact of tubing with the floor, and diminished disruptions in care. conclusions Use of a simple flexible latex-free elastomeric band may help organize therapeutic tubing at patients' bedsides and may promote improvements in nursing care. (Critical Care Nurse. 2015;35[6]:38-45) ©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015321 C ritical care patients often have numerous therapeutic connections (eg, cords, cables, and tubes) at the bedside that can easily become disorganized and tangled, leading to contamination of the connections, nurses' confusion, a physical hazard that increases the risk for falls for both nurses and patients, and the possibility of damage of medical devices.1-6 This phenomenon, known as spaghetti syndrome, makes caring for patients challenging and difficult 1,2 ( Figure 1). Multiple instances of patients' deaths, permanent injury, and life-threatening situations related to entanglement with the cords of medical devices have been reported. 5,[7][8][9][10][11][12][13][14] Ensuring the organization of cords and tubes at a patient's bedside may reduce adverse outcomes such as entanglement of the patient, backflow in tubing, falls by both patients and health care personnel, and connection errors or damage of medical equipment. [5][6][7]12 38 Therapeutic tubing, cables, wires, and cords are a fundamental aspect of daily health care for delivery of medications and fl uids to patients. The often disorganized tubing and cords at the bedside increase the possibility of inadvertently connecting the wrong syringes and tubing and then unintentionally delivering medication or fl uids via the wrong route. In 2006, the Joint Commission issued alerts on tubing misconnections; interventions and procedures to manage and protect medical cords, tubes, and cables as a standard of care, but only a few devices are available to aid in this task. 11,13,15 Few bedside devices for cord control are commercially available, and they vary in complexity and design. The purpose of this study was to test use of a novel simple, sleeved-strap banding device in the management of spaghetti syndrome in a critical care unit and to assess nurses' responses to use of the band. Before the study, no devices or standard protocols were being used to manage the syndrome. MethodsAfter a compa...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Haynes

Bowers

Young

et al. 2015

Critical Care Nurse

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“…32,37 However, the single most important risk reduction strategy is to trace all tubing back to its origin before connecting devices or infusions and to recheck connections and trace all patient tubes and catheters to their sources at the start of each shift and upon the patient's arrival to a new setting or unit as part of the handoff process. 38,39 ! Independent double-checks Reports of PN-related errors often recommend implementation of independent double-checks at critical phases of PN administration, such as order verification or programming the infusion rate !…”

Section: Tubing Misconnectionsmentioning

confidence: 99%

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

et al. 2014

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! Abstract !Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document.

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“…32,37 However, the single most important risk reduction strategy is to trace all tubing back to its origin before connecting devices or infusions and to recheck connections and trace all patient tubes and catheters to their sources at the start of each shift and upon the patient's arrival to a new setting or unit as part of the hand-off process. 38,39 Independent double-checks. Reports of PN-related errors often recommend implementation of independent doublechecks at critical phases of PN administration, such as order verification or programming the infusion rate into the pump.…”

Section: Rationalementioning

confidence: 99%

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

Ayers

Adams

Boullata

et al. 2013

J Parenter Enteral Nutr

197

230

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Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document.

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Enteral Feeding Misconnections: A Consortium Position Statement

Cited by 47 publications

References 12 publications

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

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