Reducing the risk of wrong route errors.

Infants in the neonatal intensive care unit are at particular risk from clinical errors because of their fragility and vulnerability, as well as the complex nature of medication and other treatment regimes. Wrong route errors have been well documented, particularly related to enteral nutrition and medication. Published guidance for preventing such errors should inform changes in practice at the local level. In 2005, the Regional Neonatal Intensive Care Unit at the University Hospital of Wales Cardiff undertook a change in clinical practice to improve standards of care for all babies requiring enteral nutrition and medication, thus reducing the risk of a wrong route error. A routine revision of departmental policy resulted in a review of available evidence to inform the practice changes. Colour-coded enteral/oral syringes with a new style nasogastric tube were introduced. By promoting best practice through networking with other colleagues, staff have worked towards standardising the delivery of care in order to minimise the risk wrong route errors.