Accidental intravenous administration of enteral feeds by a patient with cystic fibrosis

Young adults with cystic fibrosis are actively encouraged to take increasing self-responsibility, both at home and in hospital, for their often complicated therapeutic regimens. Many patients manage both their intravenous antibiotics and overnight enteral feeds. In our unit strict training protocols are followed to ensure that patients fully understand, and can safely perform, any procedure for which they will subsequently be responsible. Nonetheless, a 21-year-old man with cystic fibrosis admitted for treatment of his acute respiratory deterioration inadvertently attached his disconnected nasogastric feeding line to his intravenous access site during the night. Approximately 500 ml of enteral feed was administered intravenously with subsequent fevers, rigors, tachycardia, and vomiting. This is the first report of the patient, rather then the medical staff, inadvertently connecting the enteral feeding line to the intravenous access site.