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PSNet: Patient Safety Network
Journal Article

Tubing misconnections: normalization of deviance.

Simmons D, Symes L, Guenter P, et al. Nutr Clin Pract. 2011;26(3):286-293.

Analyzing published case studies on tubing misconnections and expert recommendations for improvement, this review suggests that equipment redesign—making enteral and IV systems incompatible—is the most effective strategy to reduce incidence of such errors.