Preventing Accidental Infusion Of Breast Milk in Neonates.

Vol. 35 No. 3 • March 2010 • P&T® 127 pening despite recognition of the problem more than three decades ago. Ryan et al.2 reported a similar case and noted that neonatal health professionals communicated eight previously unknown events to the authors after they posted a question about accidental milk infusion to an online e-mail discussion group. All hospital staff—particularly workers in neonatal units—must take the risk of misconnections seriously and should take steps to eliminate all chances of IV infusion or direct injection of nonsterile, particulate fluids meant for enteral ad ministration. A Joint Commission alert on tubing misconnections provided several excellent recommendations for preventing such tragedies:3