The lingering safety menace: a 10-year review of enteral misconnection adverse events and narrative review.

Despite organizational guidelines, federal reports, and equipment redesign, tubing misconnections continue to occur. This review updates the 2011 article, Tubing misconnections: normalization of deviance, with a further 96 case reports of errors resulting from tubing misconnections. Harm was reported in 69% of cases and death was reported in 4% of cases. The authors urge all healthcare organizations to transition from universal connectors to syringes and tubing designed to be compatible only with themselves (for example, use of enteral tube with a unique connector that cannot be connected to an intravenous syringe).