挥之不去的安全威胁:肠道错接不良事件 10 年回顾和叙述性回顾。

IF 2.1 4区 医学 Q3 NUTRITION & DIETETICS
Nutrition in Clinical Practice Pub Date : 2024-10-01 Epub Date: 2024-07-18 DOI:10.1002/ncp.11191
Stacie Ethington, Amanda Volpe, Peggi Guenter, Debora Simmons
{"title":"挥之不去的安全威胁:肠道错接不良事件 10 年回顾和叙述性回顾。","authors":"Stacie Ethington, Amanda Volpe, Peggi Guenter, Debora Simmons","doi":"10.1002/ncp.11191","DOIUrl":null,"url":null,"abstract":"<p><p>In 2011, \"Tubing Misconnections: Normalization of Deviance\" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.</p>","PeriodicalId":19354,"journal":{"name":"Nutrition in Clinical Practice","volume":" ","pages":"1251-1258"},"PeriodicalIF":2.1000,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"The lingering safety menace: A 10-year review of enteral misconnection adverse events and narrative review.\",\"authors\":\"Stacie Ethington, Amanda Volpe, Peggi Guenter, Debora Simmons\",\"doi\":\"10.1002/ncp.11191\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><p>In 2011, \\\"Tubing Misconnections: Normalization of Deviance\\\" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.</p>\",\"PeriodicalId\":19354,\"journal\":{\"name\":\"Nutrition in Clinical Practice\",\"volume\":\" \",\"pages\":\"1251-1258\"},\"PeriodicalIF\":2.1000,\"publicationDate\":\"2024-10-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Nutrition in Clinical Practice\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1002/ncp.11191\",\"RegionNum\":4,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2024/7/18 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"Q3\",\"JCRName\":\"NUTRITION & DIETETICS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Nutrition in Clinical Practice","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1002/ncp.11191","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/7/18 0:00:00","PubModel":"Epub","JCR":"Q3","JCRName":"NUTRITION & DIETETICS","Score":null,"Total":0}
引用次数: 0

摘要

2011 年,"管道错接:偏差的正常化 "报告了超过 100 例导致患者受伤的肠管错接案例。尽管开发出了更安全的肠道器械连接器,但自 2011 年以来,又发表了 96 例新的肠道错接病例。我们在出版物和安全数据库中搜索了 2011 年至 2023 年的报告。报告的误连接导致死亡的病例占 4%,存活并造成伤害的病例占 69%。与成人相比,报告的误连接更多发生在婴儿和儿童身上。本文概述了发生这些错接的原因、该问题的历史和更安全连接器标准的发展、与新病例相关的安全威胁和建议、当前的转换率,以及肠内营养设备转换为更安全连接器的流程步骤、教育和资源。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The lingering safety menace: A 10-year review of enteral misconnection adverse events and narrative review.

In 2011, "Tubing Misconnections: Normalization of Deviance" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.

求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
CiteScore
6.00
自引率
9.70%
发文量
128
审稿时长
3 months
期刊介绍: NCP is a peer-reviewed, interdisciplinary publication that publishes articles about the scientific basis and clinical application of nutrition and nutrition support. NCP contains comprehensive reviews, clinical research, case observations, and other types of papers written by experts in the field of nutrition and health care practitioners involved in the delivery of specialized nutrition support. This journal is a member of the Committee on Publication Ethics (COPE).
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信