Look-Alike Tubes Lead To Hospital Deaths 520
Hugh Pickens writes "In hospitals around the country, nurses connect and disconnect interchangeable clear plastic tubing sticking out of patients' bodies to deliver or extract medicine, nutrition, fluids, gases or blood — sometimes with deadly consequences. Tubes intended to inflate blood-pressure cuffs have been connected to intravenous lines leading to deadly air embolisms, intravenous fluids have been connected to tubes intended to deliver oxygen, leading to suffocation, and in 2006 a nurse at in Wisconsin mistakenly put a spinal anesthetic into a vein, killing 16-year-old who was giving birth. 'Nurses should not have to work in an environment where it is even possible to make that kind of mistake,' says Nancy Pratt, a vocal advocate for changing the system. Critics say the tubing problem, which has gone on for decades, is an example of how the FDA fails to protect the public. 'FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,' says Dr. Robert Smith."
This reminds me of the sort of problem that Michael Cohen addressed in a slightly different medical context (winning a MacArthur Foundation grant) a few years ago.
Re:Thinking out of the box (Score:4, Informative)
And the National Association of Colorblind Nurses will sue.
Re:Thinking out of the box (Score:5, Informative)
I work in a hospital -- in the pharmacy, not nursing. I can't be sure that this is generalizable to other hospital systems, but we already do have incompatible connections for almost every route. You can't connect an IV line to an oral syringe. You can't connect a gastric feeding tube to an IV line. They just don't fit.
In cases where injectable drugs have potentially dangerous routes, we have other safeguards -- if a drug is to be injected intrathecally (into the spinal fluid), there is a giant, black sticker on it that essentially says "Hold on. Take a second and review everything. This is serious business." If it is commonly given with another drug that is given intrathecally, it comes double-bagged with a giant label that says "DON'T GIVE THIS INTRATHECALLY OR SOMEBODY WILL DIE".
I don't know that these practices occur across the US, but I'm pretty sure that there are at least products on the market that do all of these things. Without the FDA making new laws.
In many cases it comes down to the resourcefulness of the nurse. I have heard of at least one case of a nurse who gave an enteral feeding intravenously. The connections were incompatible. Her solution was to attach the two ends together and keep them in place with surgical tape.
One exception that I know is a problem is in the neonatal arena. It is a specialized area without a whole lot of specialized equipment in some cases. For instance, the enteral feeding is sometimes so small and required to go so slowly that the only alternative may be to put it into an IV syringe and run it through a syringe pump. This is (and has been) a recipe for disasterous outcomes.
Re:Thinking out of the box (Score:3, Informative)
Re:How about (Score:3, Informative)
I dunno.. if you look at the protanopia and deuteranopia pics on the wiki page for colour blindness [wikipedia.org], they look pretty difficult to tell apart to me.
Re:How about (Score:2, Informative)
Or you could have unique patterns of dots and dashes running the length of the tube. Or you could repeatedly print the number "1" along the length of tube type 1, and the number "2" along the length of tube type 2. Or you could use letters of the alphabet. Or letters of the greek alphabet. Or you could make some tubes ridged and some tubes smooth.
There are literally dozens of ways to solve this problem. None of them are exactly brain surgery.
Re:Thinking out of the box (Score:4, Informative)
Checklists etc are necessary in the military because if you screw up in the military, your ability to kill people is reduced.
Wrong. I'm afraid you're letting your mindless cynicism stand in the way of higher cognitive functions.
If you screw up on military hardware, your ability to kill the enemy is reduced, but your ability to kill friendlies (the operators of the hardware, their wingmen/platoonmates/whatever, other technicians on the apron or in the laager) is enhanced. Just like in the "mecical" world.
Re:what the bleep are you talking about? (Score:3, Informative)
> interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?
Bad example. RJ-45 was designed so that RJ-11 plugs into it correctly; in fact, some vendors no longer make RJ-11 jacks (BIX) and many places just use RJ-45 DVOs even for POTS phones.
Pair one on the RJ-45 standard is reserved for the telephone. So, you can wire up a phone and an ethernet connection (using pairs 2 and 3) on the same jack. Function is then determined by what device you plug into it.
Re:How about (Score:5, Informative)
I work part time on an ambulance, and my girlfriend works as a nurse in a hospital. and while there is some validity to some parts of the story, there are also some pretty large issues with it.
There is no way you could accidentally hook up a blood pressure line to an IV line, the connections are different, the hoses look different (blood pressure lines are opaque (usually black or navy blue) and IV lines are transparent, IV lines are also less than 1/4 the diameter), and the blood pressure one is basically never separated from the cuff anyway so there's almost never a "line" to plug in. If someone has actually managed to do this one, then there is nothing in the world you could do to prevent it, because they would have had to try VERY hard to do so!
As for oxygen lines vs IV lines, same thing again, the connections are different and the lines look different (very different diameters)
The only possibly legitimate one listed was using a drug intended to be administered to the spinal cord to the blood stream. This is not a problem of tubes, this is a fairly standard medication issue, the big issue being that almost all injected medications, no matter what they are injected for, are drawn up and injected with syringes, sometimes you inject straight in to the patient (a needle in to a vein, under the skin, in to a muscle, etc (depending on the drug)) and sometimes you inject in to an IV line. (which is already in to a vein) to "fix" this isn't so simple though, a different connection depending on where you're going to inject doesn't really work, because you can't make the human skin reject the wrong type of needle if used in the wrong place.
That said, large strides are already being made in dealing with a highly related problem in hospitals. the problem being of drugs that look similar to other drugs. for example, all IV bags used to look identical, with you having to stop and read the label to make sure you have the right one (normally not a problem, except when somehow one ends up on the wrong shelf and you don't pay enough attention), they have started to change the packaging so that they look different sitting on the shelf.
Now I suppose you could take it a step further and make them all require different tubes and different IV catheters, but frequently you administer multiple medications to one patient, so you'd have to put MANY IVs in instead of just 1 now, and you'd also end up with exponentially more supplies as you need to carry hundreds of IV catheters instead of just 4 or 5 sizes.
But one of the biggest things taught over and over and over again in any medical program dealing with medication administration is checking the medication multiple times before administration... there's no better way at the moment than simply doing your job right.
Re:Not a bad idea, but ... (Score:5, Informative)
In the Denver area hospitals are frequently understaffed, but the hospitals refuse to hire many of the available nurses.
In particular the problem is that a significant percentage of new nurses can't get hired because there are policy (and regulatory? dunno) reasons that you can't have too high a percentage of staff being new graduates, due to their lack of experience. So new nursing school grads have a tough time getting hired around here.
My wife (a nurse) is involved in the training and orientation of new hires at her hospital, so she's relatively up on the issues. Also related is that there are some hospitals which are hurting financially due to the current general economic issues - a lot of that depends on the mix of patients and how they pay (insurance, if any, Medicare etc.)
There is also age discrimination for nurses in the opposite direction - my wife has been refused jobs because she's 'too old' or 'overqualified' etc. Not as bad as in the software world but it does exist.
Re:Why has no one taken this thread seriously... (Score:3, Informative)
The medical industry does have a standard: the tapered Luer fitting [wikipedia.org]. The problem stems from the fact that they use it for everything.
Re:Why has no one taken this thread seriously... (Score:4, Informative)
So nursing is just like every other profession then..