Be Ready for New Safeguards Against Wrong-Route Errors

You'll see new devices to help prevent wrong-route med administration errors.

For years we've used Luer...a universal connector...to attach syringes and tubing to catheters, IV lines, etc.

But harmful and fatal "cross-connections" keep happening.

For instance, an IV med could accidentally be connected to and infused through an epidural catheter...rather than an IV line.

Be ready when "NRFit" and "ENFit" hit your pharmacy. They're systems with specialized connectors...to keep them from being attached to the wrong type of line.

California already mandates using NRFit and ENFit...and safety groups will strongly encourage it.

Use NRFit syringes or tubing with meds that'll be given "neuraxially"...such as by epidural or intrathecal infusion or injection.

Use ENFit syringes for meds to be given "enterally"...such as through a feeding tube (nasogastric, etc).

Consider the coloring on devices as a clue to which system they belong to. NRFit will usually have yellow...and ENFit purple.

Ask your admin or med safety officer if med labels and compounding documents can specify when to use NRFit or ENFit.

Choosing the wrong type of syringe or spiking an infusion with the wrong tubing could cause cross-connections, confusion, or other problems.

For example, if you dispense an oral liquid in a regular oral syringe, a nurse won't be able to give it through a feeding tube that has an ENFit connector.

Help ensure your nurse colleagues are aware of changes...and let them know what to expect.

For instance, epidural infusions may be dispensed with NRFit tubing attached. And ENFit syringes look a little different than regular oral syringes.

Work with your team to learn about the complete systems...so you can help troubleshoot when questions come up.

Get our updated technician tutorial, Injectable Meds: Beyond Sterile Prep, to learn about more error-prevention strategies.

Key References

  • http://stayconnected.org/wp-content/uploads/2019/07/ENFit-Connector-Conversion-Schedule-for-US.pdf (8-27-20)
  • ISMP Med Safety Alert! Acute Care 2020;25(14):1-4, AA1-AA4
  • www.feedingtubeawareness.org/enfit/ (8-27-20)
  • ISMP Med Safety Alert! Acute Care 2020;25(13):1-4
  • www.ismp.org/resources/enfit-enteral-devices-are-their-wayimportant-safety-considerations-hospitals (8-27-20)
Hospital Pharmacy Technician's Letter. September 2020, No. 360923



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