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Look-Alike Tubes Lead To Hospital Deaths 520

Posted by timothy
from the no-wait-this-one-goes-in-your-mouth dept.
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.
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Look-Alike Tubes Lead To Hospital Deaths

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  • by maroberts (15852) on Wednesday August 25, 2010 @07:10AM (#33367310) Homepage Journal

    ..that's just a series of tubes, then

    • by DWMorse (1816016)
      This problem is tubular. Dude.
    • by mcgrew (92797) *

      "In hospitals around the country"

      Which country? Internet tubes are international. But yeah, I can guess, it's my country... do they have these problems in other countries?

      And what idiotic engineer (or more likely his idiot manager) had tube connects for different purposes that fit the same fittings?

      And speaking of tubes, we're all series of biological tubes. There was a band back in the '80s called "The Tubes" that were named after this phenomena.

      • by PopeRatzo (965947) *

        And speaking of tubes, we're all series of biological tubes.

        Wait, they're supposed to be connected in series? My tubes are connected in parallel.

  • by fph il quozientatore (971015) on Wednesday August 25, 2010 @07:12AM (#33367318) Homepage
    We should have the tubes manufactured by the same companies that produce battery chargers for mobile phones. Problem solved!
    • by pesho (843750) on Wednesday August 25, 2010 @07:19AM (#33367362)
      I know you are making a joke here, but somebody should mod you up as 'Insightful'. Having incompatible fittings at the ends is the easiest and safest solution. Color coding as somebody else suggested is harder - you need to prove to FDA that the color is safe and does not leach from the plastic, and it isn't as safe - people are dumb they will connect the red tube to the blue outlet if they can.
      • by characterZer0 (138196) on Wednesday August 25, 2010 @07:26AM (#33367410)

        And the National Association of Colorblind Nurses will sue.

      • by yamfry (1533879) on Wednesday August 25, 2010 @07:41AM (#33367534)
        This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.
        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: (Score:3, Interesting)

          by rtb61 (674572)

          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.

        • by neapolitan (1100101) on Wednesday August 25, 2010 @11:26AM (#33370276)

          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.

      • by couchslug (175151) on Wednesday August 25, 2010 @07:53AM (#33367614)

        The Compressed Gas Association has been using incompatible, standard fittings for (many decades), along with colored gas hose where appropriate (welding torch hose is a common example).

        The medical industry strikes me as a bit odd.

        In the Air Force, I couldn't work on aircraft beyond 12 hours excepting emergencies because performance drops off drastically after that long a shift. (It's fun mentioning this to interns just to see the looks on their faces!)

        In the Air Force, everyone working around aircraft including pilots uses a CHECKLIST because memory is acknowledged to be fallible. Memory is nice, but get caught without a job guide and it's yo' ass!

        I have more faith in military aircraft maintenance than I do modern medicine...

        • Re: (Score:3, Insightful)

          by HungryHobo (1314109)

          Those planes come in at hundreds of millions each.
          Even the cheapest seem to come in at tens of millions.

          Screw one up and it crashes and that's all down the drain.

          even if you kill a patient due to not sleeping in 48 hours there's a fair chance the hospital will avoid admitting liability and if they do then it's not going to cost more than a million or 2 unless the patient was some insanely wealthy businessman.

          The planes are worth more than the patients.
          Simple as that.

          • by couchslug (175151) on Wednesday August 25, 2010 @12:09PM (#33370976)

            I thought that too until I enlisted, but the military (well, at least the Air Force) is _highly_ safety conscious about their people in most cases. It isn't the money first, it's the mission, then the people, then the money by and large.

            You aren't expected to die to save inanimate objects, even expensive ones with wings, and checklist discipline extends to inexpensive systems. G.I.s are aware of the cost of what they work on (easy enough to look up), but don't obsess on it.

            The USAF safety culture is genuine. I find some civilian workplaces slack and indifferent to their people by comparison.

      • Re: (Score:3, Informative)

        by INT_QRK (1043164)
        All of which highlights the importance of safety engineering and the Human Systems Interface, especially for life-critical systems. Here's a decent synopsis on the field: http://en.wikipedia.org/wiki/Safety_engineering [wikipedia.org]
  • beacause (Score:3, Insightful)

    by Spaham (634471) on Wednesday August 25, 2010 @07:19AM (#33367368)

    "because the agency is so worried about making industry happy, people continue to die"

    I say bullshit.
    Industry would be more than happy to sell new tubes to every single hospital in the country !

  • by captainpanic (1173915) on Wednesday August 25, 2010 @07:19AM (#33367372)

    How about using color codes?
    Or incompatible sizes or connections?

    Damn... this is so easy to fix.

    In chemical industry, and in labs, color codes have been used for the last 15 millennia or something. It's completely standard. Just a sticker or some tape at both ends of a tube, indicating it can only be used for that gas or liquid. And in the case of non-standard liquids/gases, standard labels (you know, those with text on it) are used to indicate what it's used for, and what is in it.

  • Clearly the problem with the number of lawsuits the medical industry has to deal with is not hysterical patients, but incompetent design. Can anyone imagine,say, in an industrial setting where the water and vacuum connectors were the same. In my experience if they are they same, they are at least color coded so your eyes catches the mismatch.

    Of course there is huge a cost if tubes for different purposes are incompatible with each other, not only at the vendor level, but also at the local level for acquis

  • Poka-Yoke (Score:4, Insightful)

    by amstrad (60839) on Wednesday August 25, 2010 @07:24AM (#33367396)
    Sounds like they're in need of a Poka-Yoke [wikipedia.org] project.
  • by CatsupBoy (825578) on Wednesday August 25, 2010 @07:26AM (#33367404)
    I dont mean to sound unsympathetic, but from the article:

    These problems have been going on since at least the 1970s.

    And:

    Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups.

    Hundreds of deaths in the past 40 years doesnt sound like a really big problem.

    My son has spent a lot of time in hospitals, he had a broviac catheter (venous) and during his frequent and long stays this has never been a problem. As a layman it was painfully obvious which tube went where.

    A much larger issue, in my mind, was actually receiving the proper meds in the proper dose.

    • by kenh (9056)

      Hundreds of deaths in the past 40 years doesnt sound like a really big problem.

      Exactly - this is a story becuase most readers forget how commonplace these types of medical procedures are and how many times a day they are safely carried out. How many times do mothers delivering babies NOT get spinal anesthesia in their veins? How many times do patients not get their IV lines connected to air lines? Etc...

      I'm certain, if investigated when they occur, there is an aggrivating factor that contributed to the er

    • Re: (Score:3, Insightful)

      by mcgrew (92797) *

      Hundreds of deaths in the past 40 years doesnt sound like a really big problem.

      You wouldn't think that if your son was one of the hundreds of deaths. And in his case, it looks from your comment that there was only one tube. After my friend Charlie had a hole in her intestine repaired [slashdot.org], there was a tangled nest of tubes running every which way. It would have been way too easy for the nurse to plug the wrong tube into the wrong place.

  • by goodmanj (234846) on Wednesday August 25, 2010 @07:28AM (#33367434)

    Looks like the medical community should take a page from the computing industry. Or gas stations.

    In recent years, computer cables work on one basic principle: if the plug fits in the jack, it should work. Or worst case, it shouldn't blow up. Didn't used to be like this -- remember ps/2 mouse/keyboard ports?

    Gas stations work the same way: it's pretty much impossible to accidentally fill a gasoline car with diesel fuel, because the diesel filler tube is too large to fit in an unleaded tank's opening. (Doesn't work the other way around, of course, but diesel users are in the minority, and can be assumed to be paying attention.

    Easy enough to do this with medical tubing. Make oxygen tubing always a specific diameter, tinted a specific color, and with a special fitting on the end that only plugs into oxygen-specific devices. Same with IV tubing, different diameter, different color, different fitting.

    You don't even need the FDA to take charge to make this happen. It's not like the government regulated the USB spec, after all. All you need is a consortium of major medical equipment manufacturers to get together to agree on a standard. What incentive do they have to do this? Well, once they set a standard, EVERY HOSPITAL IN THE COUNTRY needs to buy all-new tubing, plus all the devices designed to connect to that tubing. Small manufacturers can make a fortune just selling backwards compatibility adapters.

    The Connector Conspiracy. It's a beautiful thing.

    • by Obyron (615547) on Wednesday August 25, 2010 @07:55AM (#33367628)
      You don't even need the FDA to take charge to make this happen. It's not like the government regulated the USB spec, after all. All you need is a consortium of major medical equipment manufacturers to get together to agree on a standard.

      Except you do. If you're talking about new medical equipment, it has to be approved by the FDA. There have to be exhaustive trials with each tube, a battery of tests showing that the color tinting will not leach out of the line when exposed to any one or two of a million different medications, and clinical trials to determine the incidence of allergic reactions to the tinting dye. It would could billions of hojillions of dollars and take ten years, and what we have already works. You're fighting decades of inertia for not much statistical gain. All of this is why a pair of disposable plastic forceps costs 1000 dollars when you get your hospital bill.
      • by Idarubicin (579475) <allsquiet@hotm a i l .com> on Wednesday August 25, 2010 @02:10PM (#33372436) Journal

        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.

  • Having all of the tubes be plain transparent plastic does present an issue. It's not a huge deal when a person just has one tube, such as an IV drip, but multiple tubes can get confusing. Think of the rat's nest of power plugs behind your computer desk or entertainment center, especially if all of the power cords are the same color 3-prong connections.

    My first thought it to have pale shades of color for the different kinds of tubes. However that presents a problem because the color of a tube might obscur

  • All places I fill up my car have colour coded hoses for lead-free petrol and diesel. Computers are colour coding sockets. Simple, and pretty fault tolerant (though remeber the colour blind).

    And don't think it will fix everything. On an aircraft, a non-return valve in a fuel line had different threads on the two sides so that it could not be installed wrong - supposedly, Until some idiots get out the taps and retaps the socket to take it backwards, resulting in a crash. But it seems to be a cheap mechanism f

  • RFID (Score:2, Insightful)

    by Joebert (946227)
    Make clips with RFID tags in them, and labels on them, which clip on to the tubes as soon as they're inserted into a patient. Put sensors in the things the tubes connect to, any time one of the RFID tags gets close enough to something it wasn't intended to be connected to, sound an alarm.
    • Re: (Score:3, Funny)

      by goodmanj (234846)

      Okay, so I said in an earlier comment [slashdot.org] that there's no such thing as over-engineering things when medical devices are concerned.

      You just proved me wrong.

  • by dark_panda (177006) on Wednesday August 25, 2010 @07:45AM (#33367572)

    Hmmm I wonder if this Dr. Robert Smith fellow has... The Cure... to such problems...?

  • If you have to have a zillion different tubes at hand and also of different lengths, you are bound to be out of one of the necessary ones each time. Now this can be life-threatening. Also, the time it takes to search for each of them could easily kill a few patients as well.
  • by demonlapin (527802) on Wednesday August 25, 2010 @09:18AM (#33368570) Homepage Journal
    I am an anesthesiologist, so I deal with every single one of those tubes. YMMV.

    Anesthesiology as a specialty has made vastly greater steps in safety than any other field of medicine. Part of that is that so much of our job depends on machines; we can design machine systems so that they fail gracefully and safely. Standardized fittings have been part of that safety system, so that tubing made by company A works on company B's machines. The connectors for breathing tubes are all the same.

    The problem with the Luer system (which is the connector in the article, although they never named it) is that it's so damned useful. A single connector means that you use another kind of equipment in a pinch. It means that when I dose an epidural, I don't have to hunt down a special epidural needle and syringe. When the cuff on a breathing tube needs to be adjusted, I can use a plain old syringe. I can even use those plain old syringes to fashion an emergency oxygenation kit to keep someone alive when they quit breathing and we can't get a breathing tube in place. (If you're interested, and in a hospital, take a 3 mL syringe. Remove the plunger. Stick a 7.0 ETT connector into the back of the syringe. Perform needle cricothyrotomy with the largest IV catheter you can get, attach the syringe to the catheter, stick an Ambu bag on the ETT connector, crank up the O2 flow, and start squeezing. And get a surgeon working on the formal trach right away, because you might oxygenate with this but you sure won't clear any CO2.)

    That said, it's the right thing to do.
  • by rcamans (252182) on Wednesday August 25, 2010 @09:55AM (#33369106)

    The medical industry should have an independent commission like the one over the airline industry. The air one regularly generates recommendations to the FAA, which the FAA often ignores, regarding changes and additions to FAA regulations which would make the air safer and more reliable.Setting up such a commission for the medical industry would be quick, simple, easy. Just go to the big university medical schools, approach the doctors and deans of medicine, get them to focus on a slashdot-like blog that has discussions about medical issues. Get them started on an Medical engineering task force which takes RFCs (Requests for comment) and produces RFCs (standards) for the medical industry (hospitals, doctors, med schools, medical equipment manufacturers). Currently the AMA acts to some extent in this way, and some of their standards are crap,. But they carefully avoid many areas which would "hurt" some incompetent doctors and hospitals and med equip manufacturers. So a more independent organized effort is clearly needed.
    In the above case, simple color coding, with faint coloring of the plastic tubing, in addition to colored stripe patterns, would solve the problem. You know, like the resistor color coding we electronic types had back when resistors were big enough to use the bands. (I know, I am dating myself age-wise).

    Or we could just add a medical section to slashdot and do this stuff ourselves.

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