Implementation of an enteral nutrition and medication administration system utilizing oral syringes in the NICU

NICU patients are at particularly high risk of harm and even death from medical error. In one NICU, a process change was undertaken to minimize the risk of errors resulting in the intravenous (IV) administration of enteral formulas and oral medications. In addition, a double-check system for medication doses was introduced to reduce the likelihood of medication errors. The previous practice was to deliver enteral formulas via syringe pump using TV syringes and tubing and to dispense medications in bulk bottles, drawing up patient-specific doses at the bedside. Converting to oral syringe delivery of medications and enteral formulas utilizing enteral-only tubing eliminated the necessity for Luer-Lok IV tubing and syringes, thereby reducing the potential for wrong-route error. Converting from dispensing medications in bulk to a unit-dose system permitted establishment of a double-check system in which doses are first checked by a pharmacist and then checked by the nurse before they are administered. This article describes the planning, implementation, and postimplementation process required to make this change in practice a success.