Enteral Feeding Misconnections: A Consortium Position Statement
Abstract:A 24-year-old woman was 35 weeks pregnant when she was hospitalized for vomiting and dehydration. A bag of ready-to-hang enteral feeding was brought to the floor, and the nurse, assuming it was total parenteral nutrition, which the woman had received on previous admissions, pulled regular intravenous tubing from floor stock, spiked the bag, and started the infusion of tube feeding through the patient's peripherally inserted central catheter line. The fetus died—and then the mother, after several hours of excruciating pain.
Document Type: Research Article
Publication date: May 1, 2008
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David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.
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