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:Ummm Personal responsibility? (Score:5, Interesting)
Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard? If you're a nurse at a station and you want to ensure that you have the correct tubes. Take a moment and label them yourselves if you are that busy.
Another poster stated that maybe color coding tubes would help, and I think this is a good idea, if the dyes don't cause problems in the tubing. My greater concern is that we have busy nurses asked to perform a lot of tasks and they usually get nothing but grief from patients, so they just want to get in get out and move on to the next person. Personally I've watched nurses double check tubelines and it takes all of 2 seconds. They are also tend to be the nurses who've been a nurse for more than a couple years.
A safety system which is ultimately dependent on a human to check it isn't reliable. Even the best nurse is going to be tired or distracted occasionally.
In contrast, compressed gases need different and nonswappable regulators so that you can't hook an oxygen tank into an acetylene line. This system is virtually idiot proof.
Re:Well... (Score:4, Interesting)
If a locking head needs to attach to a patient line now, i'm sure that comparing colors could add unneeded time to compare and contrast a color scheme.
If by locking head you just mean something to cap the tube, I doubt that would matter so much. Besides, you could just put your thumb over the top until you find the right colour - seriously, how long does it take your brain to match 2 colours together? I bet I could find an object of matching colour much faster than I could find an object of matching shape or size.
Funny you should ask. In the apollo program astronauts in the lunar module had a horrible mess of hoses and fittings to deal with. The rule they all memorised was red to red, blue to blue and you can see that repeated many times in the ALSJ [nasa.gov]. Its how they matched fittings to hoses.
In the case of medicine I would suggest they stick to primary colors for a set of basic properties (liquid, gas, etc) and back the code up with a pattern (say: red gets a straight white stripe; blue gets a zig zag red stripe, and so on) for lighting conditions where colours are hard to make out.
They could back that up by using different hose material for different functions. Just enough to give the hose a unique feel.
Re:How about (Score:3, Interesting)
Yeah, exactly - the FDA could change EVERY CONNECTOR on every medical device that uses tubing "tomorrow" (I assume you meant that metaphorically, not literally Dr. Smith), ignoring that changing each connector on, say, an air pipe, would require a recertification of the device. How many connecotrs in each hospital room would have to be changed? Doctor's office? Operating rooms? Ambulances? And how long would it take the industry to respond with retro-fit kits and sufficient inspectors to review all the work required, let alone the lead time needed to manufacture, distrubute and use all the new tubing required...
Libertarians - I'm confused (Score:1, Interesting)
Shouldn't the free market have already addressed this problem?
Re:Thinking out of the box (Score:4, Interesting)
And the National Association of Colorblind Nurses will sue.
You joke, but I damned well would. I've been denied many jobs that I could physically perform simply because someone who doesn't understand colorblindness lists it as a disqualifying metric in their hiring practice.
It doesn't count as a disability according to the Federal Government, but just how many damned career fields do I need to be barred from until it freaking counts as such?
Re:How about (Score:3, Interesting)
The medical devices manufacturing market has excess capacity right now. If a retro-fit kit were designed tomorrow and orders placed immediately, the parts could be in manufacturing in 2 weeks and first parts out the door in less than a month.
Re:Thinking out of the box (Score:3, Interesting)
The solution I have seen used locally is simply to use two nurses, one does the job the other runs through the check list. It might seem like a waste of wages but hey folks, it 'is' life and death. Mistakes become very rare, two people checking and you are reinforcing the presence of risk by having a monitoring nurse. An additional benefit is the significant reduction in stress of the nurses, reassuring to have some checking so you don't accidentally kill someone. Simple solutions are often the best.
I work as a nurse... (Score:1, Interesting)
In a 24 bed icu. I've read the official reports associated with many of the incidents listed in the summary.
The BP cuff was a family member forcing together two incompatible connectors in an attempt to be helpful.
Enteral feedings into venous catheters involved kluges on the part of the nurse (forcing a connection) or the doctor (using venous tubing for a non-venous site)
As an engineer (BSME) and a nurse, I say there is room for improvement. But the situation is not as dire as the summary claims.
Re:Why has no one taken this thread seriously... (Score:5, Interesting)
So we have a situation with a glut of people with nursing degrees with no nursing experience, and nobody willing to give them nursing experience. At the same time we have an aging nurse population who will soon not be able to continue, and maybe even require nurses of their own. What a fucked up situation.
So imagine you are a nurse, and you know about this situation. You are stuck in a shitty unit in a shitty hospital, like in Detroit, and you are overworked and the family members of the patients are rude and yelling at you, you have over twice the "ethical" workload because there aren't enough nurses and you can't just not give people medical care after they are admitted or you will lose your job, and you rarely see the doctors and they disrespect you when you do see them. Everyone in the unit is asking why you are there because they job sucks so much. It is pretty fucking stressful. I think at that point if you make a mistake, of any magnitude, it is understandable.
Re:Why has no one taken this thread seriously... (Score:4, Interesting)
Actually, harder than you might think. One of my coworker tells the story of when our company sat down the heads of several major hospitals to discuss.... bed pans.
The reason: each hospital in the network buys its own bed pans, from different vendors. It was realized that they would actually save a million or two a year by just, agreeing to buy one standard bed pan from one company together.
These big shots sat around for a couple of hours, and left the room with no decision. In fact, still to this day, they purchase bed pans separately.
Instead of saving millions, they wasted several thousand dollars "worth" of these highly paid executives time, and called it a day.
-Steve
Re:Why has no one taken this thread seriously... (Score:3, Interesting)
My girlfriend is a nurse, and a damn good one. Most of her friends are also nurses, so I have had plenty of opportunities to hang out with a bunch of nurses talking shop. In my observations, there are a lot... A LOT of substandard nurses out there simply because there is such a demand for them. I've heard plenty of stories about how bad they are to know that if/when I end up in a hospital, I sure as shit don't want some unknown nurse caring for me, I've met too many that are borderline imbeciles.
Unfortunately, this is not likely to change any time soon, as the Bureau of Labor continues to tout nursing professions as one with the most demand and future job growth. That along with a cushy salary and (despite what many think) fairly easy schedule and opportunity to travel, the quality of nursing is likely to stay where it is or else decline.
Re:Thinking out of the box (Score:4, Interesting)
Totally agree with you. I'm a cardiologist, and this article just is full of alarmist oversimplification. Leaders in this industry are not complete idiots, and currently all of the connectors that they describe ARE incompatible (except, as you note, the intrathecal, as it is often essentially stock IV tubing, but ports are covered with a big warning / sticker.)
Making "special" tubing, as the article glosses over, may make the problem worse (e.g. situation:
Nurse: Quick, we need an IV in this patient in the ER, his pressure is low.
Tech: We don't have any IV tubing in this bay, but there is some black intrathecal tubing.
Nurse: Let's just use that for now (a tube is a tube) for the IV and change it later. It is an emergency.
Tech: Ok.
5 minutes later, somebody comes along with spinal anesthetic, and now that it is "safe" with a color-coded tube, doesn't trace the tube to the insertion and just injects it into the patient.)
All safety legislation / efforts have consequences, and may not actually make people safer. Here, the situations described are *EXTREMELY RARE*, and frankly, likely due to negligence (I don't have exact details for each instance, but likely the person did not trace the tube, or jury-rigged incompatible connectors together.) Safety cabling may lead to a false sense of security, and current connectors are already incompatible. There is no shortcut or excuse for constant vigilance.
It comes down to people (Score:2, Interesting)
At the age of 8 my daughter went for dental surgery. We decided to have the procedure performed in the hospital rather than the dental office for safety sake. What could go wrong? To make a long sad story short, she died for 6 to 9 minutes. Nobody is quite sure because....NONE OF THE MONITORS WERE TURNED ON. The only person in the OR was the dental surgeon and he noticed her fingernails turning blue. She was long dead by this point.
As it turns out, the anesthesiologist had mistakenly given her a triple dose of morphine which in turn stopped her heart. Too bad they were all having a coffee prior to turning on the monitors. It was "only" dental surgery after all.
To thier credit (?) they brought her back to life. Around 90% of her brain was dead by that time. She had some stem function but even that was spotty as her body could not control temperature, etc. Stage one coma for a year, vent, etc. So after a year of being told there was no hope we made the DNR decision and pulled the tube. We were taken to a nice atrium (death room) with doctors and clergy present. They pulled the vent, 45 seconds later she gasped for breath and everyone about fell over. They hustled us out so fast it would make your head spin.
Many years and over a million dollars of therapy later, she can function. Had to relearn everthing and I mean EVERYTHING. She will always have a mental age of 12yrs (16 now) very bad motor skills (never drive) blind in left eye (optics fine, neural pathway not fine) and if you saw her on the street you would think she was "retarded". How I hate that fucking word.
So all the fancy procedures, fancy equipment, etc dont mean sweet fuck all if a HUMAN doesnt turn them on.
To finish, yes of course there was a settlement...thats going to give her life back right? Money means fuck all.
Re:Why has no one taken this thread seriously... (Score:5, Interesting)
>Is it convention to use all clear, indistinguishable tubes? Yes.
The problem with your argument is that it is completely false. It is not at all a convention to use "all clear, indistinguishable tubes". IV tubing is clear. A nasal cannula for oxygen is maybe a little similar, but larger, more flexible, and (most importantly) uses a completely different Christmas-tree-type connector instead of a Luer adaptor. Nasal feeding tubes are similar in size to IV tubing, but are opaque and white. And so forth...
These devices really do look quite a bit different. Errors like this probably occur once in several thousand times they are used, and it is very hard to reduce "rare events" to "zero events". Nonetheless, the health care industry is highly sensitized to issues like this, and there has been a huge push to enact safeguards to make it even harder for such errors to occur.
Do you even work in health care or any direct knowledge of what you are talking about? (I'm a surgeon). It doesn't seem like it.
It is really telling that the Slashdot crowd mods something to "+5, Insightful" when the post is so factually clueless. I cringe whenever I see something related to medicine get discussed on Slashdot, because we invariably wind up with a bunch of smart IT guys giving opinions about things that they know very little about.
Re:Parallels with computer cabling (Score:4, Interesting)
It would could billions of hojillions of dollars and take ten years, and what we have already works.
Your post makes some excellent points, and I agree with everything that you said. I'd go even further, and note that the transition process would almost certain result in a large number of injuries and deaths as well.
Changing all of the fittings means simultaneous retraining of all the medical personnel who handle them. Patient care will be hindered because medical professionals will take more time to carry out important actions (until they become familiar with the new tools). Nurses will spend more time hunting for correct fittings and plumbing bits. Even when staff become used to the new tools, facilities will have to carry more different fittings and attachments. Procedures will have to be repeated because someone started with the wrong tool. Oh -- you used a needle with an arterial fitting rather than an IV one? You're going to have to puncture the patient again.
For some period of time, the new equipment will have to coexist beside the old. What do you do when the new drug bag isn't compatible with the old IV line? Inevitable supply line kinks may mean that hospitals receive a mix of old and new product, especially if there are occasional shortages of the new stuff.
What happens when the paramedics have inserted lines and performed other tasks using the newly-supplied fittings in their ambulance, only to arrive at a hospital that's still running through its stock of old equipment? How much room for trouble is there in the world of disposable cross-connectors and old-new converters (there will likely be at least two for each new connector) that all the hospitals and ambulances and doctors' offices will have to carry for the years it will take for all the old connectors to work their way out of the system?
Regardless of how much pre-release testing goes on, it's almost certain that at least one of the new connector types/shapes won't turn out to work as well as it should, and then we'll have to throw in another transition period to another type of equipment.
People will die.