New and Improved?

A brand of enteral nutrition formula just revamped its packaging which almost gave me a heart attack when I first saw it hanging in one of my patient's room.

As seen on the above picture, the new packaging in the middle is a 1.5 calorie/mL formula, but the color of this new label is the same color as the old label of a 1 calorie/mL formula that we are used to.

At first, I thought the nurse made an error and hung up a wrong formula. I was very close to filing a report with the Patient Safety Net, a portal to report medical errors. But when I looked at the label more closely, it's the same strength of formula that I recommended. Whew~

Think of it this way: our critical care patients are already at high risk of malnutrition. If the hung formula is indeed a 1 calorie/mL, the patient in critical condition is receiving 33% less calories than intended, hospital-acquired malnutrition may result.

The next time any manufacturer plans to make changes to their packaging, please consult our fellow dietitians and nurses who are the bedside guardians of our patients.