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 ...