Incidents and adverse events in enteral feeding tube users: warnings based on a cohort study.

Introduction: few studies clearly describe incidents or adverse events that occur during the enteral nutrition process, which hinders the identification of critical points. Objective: to describe breaches of protocol, incidents and adverse events, during the period beginning with indications until the use of enteral feeding tube in an Emergency Department. Method: trained nurses prospectively monitored a cohort of adults in a Brazilian Emergency Department where use of enteral feeding tube was indicated and up to their use. The study sought to identify breaches of protocol, such as verbal orders to insert feeding tubes, or authorization of their use without X-rays to confirm the position of the feeding tubes. Incidents were characterized as events that could have caused harm to patients, while adverse events were those that did actually cause harm. The study was approved by the institution’s Research Ethics Committee. Results: in 150 feeding tube insertions, there were 169 breaches of protocol: verbal orders for feeding tube insertion (n = 59); no X-rays taken (n = 11); and no examination of the X-rays by physicians (n = 12). There were 30 incidents: unintentional removal of the feeding tube (n = 23); and administration of enteral nutrition after breach of preventive barriers. There was one adverse event: aspiration of enteral nutrition. Conclusion: there was a high frequency of breaches of safety protocols; many developed into incidents, and one resulted in an adverse event.