print this page

Home Nutritional Product Ordering and Delivery

What are High-Risk Enteral Formulas?  High-risk enteral formulas are specialized formulas, such as metabolic and amino acid-based, that can cause injury or even death if given to the wrong patient.  Patients that require these formulas are also at high risk for injury or death if they do not receive the correct formula for their condition.  Serious events reported by other healthcare facilities prompted Baystate Home Infusion & Respiratory Services (BHI&RS) to examine existing processes for any weaknesses that could allow such an event to reach or impact the patient, and then to redesign them.  The redesign team examines ways of reducing the risk and is focused on improving the safety of ordering, selecting, and delivering all enteral formulas to our patients. 


Enlarge graph




Baystate Home Infusion & Respiratory Services 

Based on the team’s feedback, several interventions have been put in place to improve the safety of the processes. 

  • High-risk enteral formulas were separated from general stock through warehouse redesign with new shelves and signage. 
  • A designated, color-coded section of shelving was established to separate and highlight special handling, and to separate all look-alike, sound-alike formulas.
  • A time-out procedure was initiated to double check high-risk enteral orders and verify that the correct formula was selected. 
  • A new package labeling system was developed and implemented to ensure that multiple packages for the same patient delivery could be easily identified by the driver or nurse.
  • Another intake coordinator was added who handles all the oral enteral product referrals, allowing for faster processing and getting the needed formula to the patient. 
  • We also assigned the job of picking orders in the morning to one staff member in the warehouse.  This has increased the accuracy of our enteral deliveries and reduced the risk of patient harm from receiving the wrong formula. 
  • Formulas are being entered into the system using TALL letters for part of a name that is descriptive in reducing the risk for the wrong formula being entered on the delivery slip.
  • When receiving new orders, previous orders are discontinued, including changes in amounts.
  • The Enteral Product Line Group meets every two weeks to focus on our enteral product line and improving customer service.  The group includes a supply clerk, intake representatives, a registered dietician, warehouse staff, managers, and quality control staff.
  • In addition to those safeguards, we have instituted a process to eliminate errors made at the creation of the delivery ticket. 
    • The supply clerk checks the initial ticket with the order and then cross-checks it with a clinician. 
    • The formula delivered to the home is double-checked with the patient and/or caregiver to ensure the delivery is correct.


For more information on Quality at Baystate Health

For more information on Baystate Home Infusion and Respiratory Services