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A.S.P.E.N. Patient Safety Initiatives

A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. A.S.P.E.N.'s mission is to improve patient care by advancing the science and practice of nutrition support therapy.

Table of Contents:

A.S.P.E.N. - ISMP Error Reporting Project
2009 Enteral Nutrition Practice Recommendations
Be A.L.E.R.T., Be A.W.A.R.E., and Be R.E.A.D.Y. Enteral Safety Campaigns
Oley Foundation PN Access Device Safety Initiative
A.S.P.E.N. Resources
FDA Leur Misconnections Calendar
National Patient Safety Foundation 

NEW A.S.P.E.N. Patient Safety Initiatives

2010 A.S.P.E.N.-ISMP Error Reporting Project

A.S.P.E.N. has set up a collaborative project with the Institute for Safe Medication Practices (ISMP) to educate clinicians about error reporting with nutrition support therapy.

The goals of this project are to:

  1. Educate healthcare professionals about nutrition support therapy error reporting (what events to report, what information to include, and how to report them).
  2. Partner with ISMP in gathering data from clinicians on nutrition support therapy and device errors and share information with our constituents.
  3. Develop educational strategies to reduce errors.
  4. Collaborate on national initiatives that address error reduction for nutrition support therapies.

To learn more about this program and to report nutrition support errors to ISMP go here.

2009 Enteral Nutrition Practice Recommendations

A.S.P.E.N. has developed The Enteral Nutrition Practice Recommendations to share with the multidisciplinary teams responsible for delivering EN – including clinicians, administrators, educators and researchers, the healthcare community, patients, and their caregivers - in an effort to optimize Enteral Nutrition practices.

The specific topics covered in the recommendations include:

  • Ordering and Labeling of Enteral Nutrition
  • Enteral Formula (Medical Foods) and Infant Formula Regulation
  • Water and Enteral Formula Safety and Stability
  • Enteral Access
  • Enteral Nutrition Administration
  • Medication Administration
  • Monitoring Enteral Nutrition Administration

Printable .pdf
Purchase a bound copy 

Be A.L.E.R.T., Be A.W.A.R.E., and Be R.E.A.D.Y. Enteral Safety Campaign Posters

As part of efforts to improve enteral safety and translate our Enteral Nutrition Practice Recommendations to the bedside, we are excited to announce the  launch of the Be A.L.E.R.T. (2009),  Be A.W.A.R.E. (2010), now Be R.E.A.D.Y. campaign. This A.S.P.E.N. safety campaign, sponsored by Nestlé HealthCare Nutrition, is aimed at educating nurses to help prevent enteral misconnections and improve enteral nutrition safety.  This initiative includes the Be A.L.E.R.T., Be A.W.A.R.E., and Be R.E.A.D.Y. posters for nursing stations and other prominent places in your hospital.  The new Be R.E.A.D.Y.  poster (2011) is specifically focused on Pediatrics and Enteral Nutrition. The Be A.W.A.R.E. poster (2010) is a safety poster specifically focused on Medication Safety through Enteral Feeding Tubes. Please share these with your coworkers and encourage safe enteral nutrition delivery. We want to hear about your efforts, so please be sure to give us your feedback and let us know how we can improve the campaign and what other resources you might need.

You can obtain the posters in the following ways:

Click on the link below for a .pdf version of the poster:

Be A.W.A.R.E. Poster (.pdf)
Be A.L.E.R.T. Poster (High Res .pdf)
Be A.L.E.R.T. Poster (Low Res. pdf) 
Be R.E.A.D.Y. Poster (Low Res)
Be R.E.A.D.Y. Poster (High Res)

If you would like the cling poster, contact Nestle HealthCare Nutrition at 1.800.422.ASK2 (2752) and ask for the Be A.L.E.R.T. posters to be mailed to you (maximum number is 20 per location).

For further information on these campaigns, please email Peggi Guenter with the A.S.P.E.N. office.

Oley Foundation PN Access Device Safety Initiative

Keep Me Safe Posters and Bracelets: This laminated poster and wrist band are designed to protect consumers and their "lifelines" while in hospital. The poster encourages hand washing and other aspects of sterile line care, and should be posted on the consumer's hospital chart. The bracelets are worn on the consumer's wrist (next to their hospital I.D. band) to reinforce the care needed for these special lines. The poster can be downloaded below; or order your FREE laminated copy and FREE bracelet from the Oley Foundation.

Keep Me Safe Poster (best printed in color)

Click here to order printed copies of the chart and a bracelet - FREE of charge


A.S.P.E.N. Resources

A.S.P.E.N. offers these linked resources for you to use to improve patient safety and understand the issues related to potential risks of parenteral and enteral nutrition. Below please find A.S.P.E.N. journal articles and current initiatives in progress. Many of these initiatives and documents include collaborating with other organizations to meet the goals of delivering safe, efficacious patient care. 

Safe Practices for Parenteral Nutrition

Mirtallo J, Canada T, Johnson D, et al; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr 2004;28:S39–S70. Errata 2006;30:177

A.S.P.E.N. Statement on Parenteral Nutrition Standardization

A.S.P.E.N. Board of Directors and Task Force on Parenteral Nutrition Standardization, Marty Kochevar, Peggi Guenter, Beverly Holcombe, Ainsley Malone, and Jay Mirtallo. JPEN J Parenter Enteral Nutr, Sept-Oct 2007; 31: 441 - 448.

Invited Commentary: Improving Safety and Reducing Harm Associated With Specialized Nutrition Support 
Marion F. Winkler. Nutr Clin Pract. Dec 2005; 20: 595 - 596.

Invited Review: Nutrition Support Teams: An Evidence-Based Practice 
Philip J. Schneider. Nutr Clin Pract. Feb 2006; 21: 62 - 67.

Invited Review: Reinstituting Oral Feeding in Tube-Fed Adult Patients With Dysphagia 
Michael A. Crary and Michael E. Groher. Nutr Clin Pract. Dec 2006; 21: 576 - 586.

Editorials: Patient Safety 
Charles W. Van Way, III. JPEN J Parenter Enteral Nutr. Jan 2005; 29: 61 - 62.

Original Communications: Enhancing Patient Safety During Feeding-Tube Insertion: A Review of More Than 2000 Insertions 
Rachel Sorokin and Jonathan E. Gottlieb. JPEN J Parenter Enteral Nutr. SEPTEMBER-OCTOBER 2006; 30: 440 - 445.

Note: Patient Safety and A.S.P.E.N. Publications and Documents

Our policy at A.S.P.E.N. is to update our publications and documents at a minimum of at least every five years to ensure that we include only the most current information, including the latest patient safety information. We have a new Adult Core Curriculum (2007) and a new Nutrition Support Practice Manual (2006) which covers peds and adults. Our new Pediatrics Core is currently under development and will be available in 2010. Patient safety is a major concern for A.S.P.E.N. and we strongly encourage you to use the most current publications and literature, and of course your best judgment. We welcome any ideas you may have to improve patient safety.

December 2009 - The American Dietetic Association (ADA) House Leadership Team on behalf of the House of Delegates and the Dietitians in Nutrition Support (DNS) DPG approved ADA's endorsement of A.S.P.E.N.'s Enteral Nutrition Practice Recommendations as published in the March 2009 issue of Journal of Parenteral and Enteral Nutrition (JPEN). The endorsement is based on the input of ADA's Evidence-Based Practice Committee and DNS DPG regarding these recommendations and is effective as of December 2, 2009.

2009-2010 A.S.P.E.N. Staff continues to work with manufacturers of fat emulsion and IV vitamin low inventory states.

August 2008: A.S.P.E.N. members Marty Kochevar, MS, RPh, BCNSP, Ginger Langley, PharmD, BCNSP, Jay Mirtallo, MS, RPh, BCNSP, Kris M. Mogensen, MS, RD, LDN, CNSD, and Gordon Sacks, PharmD, BCNSP participated in the Second Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems along with 46 other national participants. The Conference culminated in the development of numerous consensus statements (including PN) that was published in AJHP 2009; 66:185-92.

July 2008- Beverly J. Holcombe, PharmD, BCSNP, FASHP served as the  A.S.P.E.N. representative and participated as an expert panel member at the ASHP IV Safety Summit along with leaders from most major healthcare organizations. The goal of this premier summit was to bring about changes that prevent further harm or death from intravenous medication errors. 

July 2008- A.S.P.E.N. staff notifies membership of product recalls and shortage - IV multivitamin low inventory 

May 2008- A.S.P.E.N. member served as lead author in Enteral Misconnections paper in May 2008 issue of The Joint Commission Journal on Quality and Patient Safety.

2008-2009 A.S.P.E.N. representative to be appointed to Association for the Advancement of Medical Instrumentation (AAMI) Working Group in order to develop manufacturing standards for enteral connections.

2008-2009 A.S.P.E.N. Public Policy Committee working with USP/ISMP on enteral and parenteral nutrition adverse events reporting program. Education and data analysis projects are being planned.

2007-2008 A.S.P.E.N. works with the Joint Commission to rewrite FAQ on 2007 National Patient Safety Goal 3B on parenteral nutrition and Task Force writes Parenteral Nutrition Standardization Statement (see reference above).

November 2007- Clinical Practice Committee responds to ISMP alert November 2007 pertaining to its Safe Practice Recommendations involving a case report of a fatal 1000-fold overdose of zinc in a neonatal parenteral nutrition. A.S.P.E.N. will continue dialog with ISMP.

Food and Drug Administration Luer Misconnections Calendar

Patient injuries and deaths have occurred when different device delivery systems are mistakenly connected to each other. These errors are often facilitated by fittings called Luer connectors, which can allow different systems to be easily, but erroneously, connected.

The 2009 Medical Device Safety Calendar (Luer Misconnections) is one of FDA’s efforts to help educate healthcare professionals about these dangerous misconnections. The calendar provides a graphic depiction of a variety of misconnection cases, coupled with recommendations from The Joint Commission (TJC) on ways to prevent these types of errors.

On this website, you can download or print the calendarcase studies, and additional resources about Luer misconnections and how to help prevent them. Clinical facilities may request copies of calendar, free of charge, at while supplies last.

National Patient Safety Foundation

Patient Safety Awareness Week (PSAW) is a national education and awareness-building campaign for improving patient safety at the local level and will be March 7-13th, 2010. Hospitals and healthcare organizations across the country are encouraged to plan events to promote patient safety within their own organizations. Educational activities are centered on educating patients on how to become involved in their own health care, as well as working with hospitals to build partnerships with their patient community. For more information visit: