Risk assessment is a valuable tool that supports decision-making in lowering morbidity and mortality due to medical errors through a systematic approach based on evidence. Since nutrition is considered a medical treatment and not just a physiological support, it is subject to adverse events and therefore to risk management. Artificial nutrition is also strictly connected to a sentinel event: catheter and tubing misconnection due to inadvertent infusion of a feeding into an intravenous line. Among its nine Life-Saving Patient Safety Solutions, the WHO Collaborating Centre for Patient Safety has just released recommendations aimed at avoiding misconnections. Despite the acknowledged importance of appropriate provision of nutrition in critically ill and surgical patients, disease-related undernutrition is too rarely treated with nutritional therapy. The strong evidence supporting it should encourage its more widespread use in this setting. Furthermore, lessons learnt from adverse events must be shared among health-care providers, because safety improvement is in everybody's interest.
