The past decade has seen several cases of injury and death due to the maladministration of non-IV fluids. Enteral feeding equipment fitted with universal luer connectors has allowed clinicians to inject enteral medication into parenteral lines inadvertently. In response to these incidents the NHS in UK and the US Institute for Safe Medication Practice have collaborated with the Joint Commission in recommending the use of specialty syringes for all oral / enteral medication. In order to further encourage non-compatibility with hypodermic needles or needle-free IV access ports, a new standard, BS EN 15546-1:2008 was issued in June 2008 to specify the use of a non-luer tip for oral / enteral medication. Enteralok was designed to comply with this standard and prevent maladministration.
NPSA Recommendations
In response to this the National Patient Safety Agency has issued guidelines on the use of Syringes for enteral feeding:
• An appropriate oral/enteral syringe should be used to measure oral liquid medicine if a medicine spoon or graduated measure cannot be used.
• Only use well-labelled oral/enteral syringes that do not allow connection to intravenous catheters or ports.
• Enteral feeding systems should not contain ports that allow connection to intravenous syringes.
• Three-way taps and syringe tip adapters should not be used in enteral feeding systems as they allow connection design safeguards to be bypassed.
• Catheter tip syringes are commonly used in practice to measure and administer large volumes of medicines and feeds. These syringes are not sufficiently accurate to measure or administer small volumes of these medicines.
