Available Until 2/24/2023

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

NOTE: If you attended the live CE activity that was held on February 24, 2021 AND received CE credit (i.e. a Pharmacist or Pharmacy Technician CE statement of credit with ACPE UAN 0221-9999-21-016-L05-P/T), you are NOT allowed to also receive credit for this home-study on-demand web activity. 

Activity Description

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.

Target Audience

The intended audience for this activity includes Pharmacists, Pharmacy Technicians, Medication Safety and Patient Safety Officers, Quality and Risk Management Leaders, Hospital and Health System Leadership, Nursing and Pharmacy Managers and Administrators.

Learning Objectives

At the completion of this activity, the participant will be able to:

  • Describe the safety challenges associated with wrong route enteral-IV medication errors.
  • Reflect on the hierarchy of strategies used to support safe enteral administration of medications.
  • Identify continued opportunities for national improvement towards the prevention of wrong route errors.
  • 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


It is the policy of ProCE, LLC to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants any significant financial interest or affiliation with companies that manufacture or market products discussed during their presentation. Michael Cohen, Juuso Leinonen, Felix Lam and Emily Spellman have no relevant commercial or financial relationships to disclose.

CE Accreditation

Release Date: February 24, 2021

Expiration Date: February 24, 2023

Pharmacists/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 0221-9999-21-016-H05-P/T has been assigned to this knowledge-based home study CE activity. This CE 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 www.ProCE.com 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 an educational grant from Avanos.


The material presented in this CE activity does not reflect the views of ProCE, LLC or the commercial sponsor. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.