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Call to Action: Experience in Adopting the ENFit System to Guard Against Accidental Tubing Misconnections

Catheter misconnections involving enteral-to-IV tubing are well documented in the patient safety literature.  They often lead to severe consequences for patients and families. Despite the recent adoption of connector design standards for enteral devices (ENFit™), a Joint Commission Sentinel event advisory in 2014, and a consortium of manufacturers to support compliance and rapid development of ENFit devices in hospitals and health systems, the US response has been underwhelming at best. Initial adoption delays associated with previously unidentified problems in clinical practice led to the re-engineering of a new low-dose tip ENFit syringe. However, even with these improvements, due to the complexity of the change that is required, a large number of organizations have yet to be fully compliant with this transition—leaving patients in a vulnerable position.

Join ISMP faculty as they review the many challenges associated with wrong route errors, discuss the product design concerns that led to the re-engineering of the new ISO standard and the low-dose tip syringe. Most importantly, we will highlight the patient safety benefits to an ENFit transition. Also, hear directly from an organization who has successfully made the ENFit transition, their practice implications, and the lessons learned in the implementation of ENFit-compliant devices to advance patient safety.

Begin Activity


Learning Objectives

  1. Describe the safety challenges associated with wrong route enteral-IV medication errors. 

  2. Reflect on the hierarchy of strategies used to support safe enteral administration of medications.

  3. Identify continued opportunities for national improvement towards the prevention of wrong route errors.

  4. Share in first-hand implementation experiences from a healthcare organization's adoption of ENFit-compliant devices.


Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, President, ISMP

Juuso Leinonen, Senior Project Officer-Health Devices, ECRI

Felix Lam, PharmD, MBA, BCPS, Pharmacy Operations Manager, Pediatrics, University of Iowa Stead Family Children’s Hospital

Emily Spellman, MSN, RNC-NIC, Associate Director, Neonatal Services, University of Iowa Stead Family Children’s Hospital

CE Accreditation

Release Date: February 24, 2021
Expiration Date: February 24, 2025

Pharmacists and Pharmacy Technicians
This CE activity is jointly provided by ProCE, LLC and the Institute for Safe Medication Practices (ISMP). ProCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number 0221-9999-23-016-H05-P/T has been assigned to this knowledge-based home-study CE activity. This activity is approved for 1.0 contact hour (0.1 CEU) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Statements of completion will be issued online at upon completion of the evaluation and post-test with a score of 70% or higher. Proof of completion will be posted in NABP CPE Monitor profiles. No partial credit will be given.

This activity is supported by Avanos.


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