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.
Its not just the internet (Score:5, Funny)
..that's just a series of tubes, then
Re: (Score:2)
Re: (Score:3, Funny)
i don't know, but it reminds me of the scene from Idiocracy where the "Doctor" tells the protagonist to put one probe in his mouth and the other in his rear, then realizes he made a mistake and asks him to switch them.
http://www.youtube.com/watch?v=8CHY41trBFQ&feature=search [youtube.com]
about 0:40 into the trailer.
Re:Why has no one taken this thread seriously... (Score:5, Insightful)
Ideally, nurses aren't working 12- and 14-hour shifts back-to-back because of critical understaffing and/or cost-cutting, and aren't responsible for about 2-3 times as many patients per nurse as they ought to be. Ideally, said nurses aren't fatigued and stressed to hell and gone. Ideally, no one ever makes a mistake when they are exhausted, rushed, and stressed. Ideally, if anyone makes a mistake, it will be completely innocuous and won't kill or maim anyone or cause massive property damage.
Unfortunately, I don't live in that ideal world, and neither do any nurses I know of. That doesn't make them "purely incompetent"; it makes them human beings living in the real world.
Based on this NY Times article, the current state of things in the medical devices world is fucking retarded! In the electronics world, we carefully make incompatible devices with incompatible plugs, and/or use color coding for similar plugs (keyboard/mouse and microphone/speaker/line-in come to mind). Apparently making sure customers don't fry their home electronics is more important than making sure patients don't die. Apparently the medical devices industry hasn't heard of something like "industry standards". How bloody hard is it to get together with your industry standards organization and publish a standard that says all IV tubes have a plug type A, all air tubes have plug type B, etc?? This is basic industrial and safety engineering--it's not rocket science.
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
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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.
Unfortunat
Re:Why has no one taken this thread seriously... (Score:4, Informative)
So nursing is just like every other profession then..
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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, Insightful)
How bloody hard is it to get together with your industry standards organization and publish a standard that says all IV tubes have a plug type A, all air tubes have plug type B, etc?? This is basic industrial and safety engineering--it's not rocket science.
It's very hard because to establish a standard, you need to demonstrate a need,
but a need implies a short-coming and of course known short-comings demonstrate liability.
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If paying your nurses overtime for back-to-back 12 hour shifts is a "cost-cutting" measure compared to just hiring another nurse, YOU'RE DOING IT WRONG.
Re:Why has no one taken this thread seriously... (Score:5, Insightful)
Based on this NY Times article, the current state of things in the medical devices world is fucking retarded! In the electronics world, we carefully make incompatible devices with incompatible plugs, and/or use color coding for similar plugs (keyboard/mouse and microphone/speaker/line-in come to mind).
Actually that's only been the case starting in the late 90s. Earlier than that, and you could get sound cards with nothing more than nearly invisible etched markings to indicate what the ports were for or completely unmarked keyboard/mouse PS/2 ports. And that's just outside the case. Inside, before mobo makers started catering to the build-your-own crowd, was a complete fucking nightmare. ATA disk cable connections didn't even have guides, much less a notch to prevent you from putting them in backwards. Oh, and the fucking AT power connector consisted of two separate connectors that went in side by side with nothing preventing you from hooking them up backwards, guaranteeing a short and the death of (at least) your mobo if you turned the power on.
The best part was when the manual had a typo when specifying pin 1 of a given connector. Oh yeah, those were fun times.
Anyway, I think my point is, even the electronics world took a while to get its shit together, and that was mostly inspired by an influx of amateur enthusiasts. I can't say I'm surprised that the medical profession doesn't aggressively leap on new standards when, because everyone is highly trained, the existing methods mostly work.
Re:Why has no one taken this thread seriously... (Score:5, Insightful)
Now, the case with tubes in the medical industry is not analogous. Is it convention to use all clear, indistinguishable tubes? Yes. Has this single convention demonstrably gotten people killed? Yes. Would it really be impossible to make sure all oxygen tubes were blue, all liquid tubes pink, and all gas tubes green, or something similar? No. Should, therefore, the convention be changed? Yes.
The the backwards current issue is about as benign as basing all of our coordinate mathematics of "right hand" conventions. It really doesn't matter in the large scope of things. The medical tube convention is similar to using the same interface plugs for audio wiring as is used for power jacks, it's a practical application that can lead to costly fuck ups.
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:Why has no one taken this thread seriously... (Score:4, Insightful)
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.
If the adapters are different, how is it even possible for the error to occur? If there are some types of tubes that use different connectors such that they can't be connected incorrectly, but other types of tubes that aren't different and thus makes error possible, why not fix that subset? If the adapters are different, but not so different that you can't incorrectly stick them together, why not fix that?
Re:Why has no one taken this thread seriously... (Score:5, Insightful)
You have scientists and engineers who have long been using the incorrect convention and do not want to change because all of their work has been based on it. On the other hand, you have students who are trying to learn a model that is physically wrong, and they are wasting time and energy doing it. When you get to semiconductors, things REALLY suck.
No, we don't want to change because it'd take tons of work and is completely irrelevant. Students aren't learning anything wrong, they're just learning a convention for a unit. How much time and energy does it take to learn "Current is defined to be in the direction of positive current flow, but it's actually the negative charge carriers that move, so when you calculate a positive current in one direction, it means electrons are flowing in the opposite direction". Oh right, as long as it takes to say that sentence, and maybe explain why (because at the time the convention was made, we didn't know which it was that was actually moving, but we still needed a convention).
It doesn't suck for semiconductors at all, it's still irrelevant. For a MOSFET, you calculate your doping and number of dots/holes, calculate the amount of electrons that will flow across at a given source/drain/gate voltage, and then when you want to specify that flow in terms of current, you flip the sign. Woopty-fucking-do! To go from current to electron flow to analyze problems like electron migration, you just -- what was that again -- flip the sign. By the time you get to semiconductors, this should be utterly second nature.
If you wanted, you could get rid of the "wrongness" by simply defining current to be negative in the direction of negative charge movement, and not have to change a single calculation. It's mathematically and logically indistinguishable.
And then you get beyond talking strictly about currents through conductors, realize that a proton beam is a current in which -- GASP -- it's the positive charge carriers that are moving, so the "current is in the direction of negative charge movement" convention would be equally "wrong", and hopefully realize that it really doesn't fucking matter how you set your convention.
You just have to understand that some things that people say are more abstract than you may be able to comprehend. If you haven't spent time with microelectronics (many here have), this might not be your argument to fight.
Yeah, it's an abstraction with no practical consequence what-so-fucking-ever. Get over it!
If you're still lost, think about it this way. Medical equipment is a huge expense, and it's neither cheap nor trivial to just go in and replace it without costing the industry probably billions of dollars in the short term which means that you and I pay these billions of dollars. Got it?
Yeah, but not everything needs to be replaced. Connectors and tubes. Expensive, sure, but still completely unanalagous to the current convention. Lemme break it down for you:
Current convention:
* Affects every single current calculation done by electrical engineers, ever.
* Has absolutely zero real-world consequence
Medical tubing:
* Affects only a subset of medical devices.
* Has practical real-world consequences in the form of preventable deaths.
So, yeah. One is crazily expensive and not worth doing anything about regardless of cost because it is meaningless. The other is expensive, but doesn't require replacing everything, and has demonstrable value which must be weighed against the cost.
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Using clear tubes with a colored stripe running the length might be a better solution - you can still see through the tubes but they're harder to mess up.
This system is an accident waiting to happen, obviously. We don't use all-black wires in electrical systems even though a competent electrician could trace them back to the source.
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.
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Re:Why has no one taken this thread seriously... (Score:5, Insightful)
If you're connecting an air hose to an IV, there is something really wrong. Any nurse who does something like this is purely incompetent. I know several RNs and talk to a few on a daily basis. It is a somewhat stressful and fast-paced job, but you cannot ethically exceed your working pace. Every nurse should physically trace each tube to its receptacle. If there are two tubes in the vicinity but not even in proximity, extra care should be taken to trace the tube tactilely. The government-protectionist tone here ("Critics say the tubing problem, which has gone on for decades, is an example of how the FDA fails to protect the public.") is absurd and gives you NO excuse to shed the responsibility for your actions.
If these devices can be designed so this can't happen, then designers, manufacturers, etc. are also not taking responsibility for their actions. It's all well and good to point fingers at the end user, but if you built this stuff and you could have made it more foolproof and didn't, you failed too. It is not necessary of even advisable to have a device with only one layer of defense against misuse. This is a design flaw.
For an excellent example of this sort of design failure, see the Therac-25 case [wikipedia.org]. Therac-25 case used to be taught in just about every system design class for a while. Unfortunately, this happened so long ago that programmers and s/w engineers forgot the lesson and a similar problems have happened [theledger.com] again [nytimes.com].
Everyone who designs anything that gets used by anyone should read The Design of Everyday Things [amazon.com] to disabuse themselves of the notion that it's always the fault of the stupid, incompetent, careless, rushing, undertrained user.
Yes, it's harder. No, you can't anticipate everything. But every problem you can prevent is a person not frustrated, something not broken, money not wasted or even a life saved. So even if you can't do it 100% foolproof, it doesn't mean you don't try your damnedest. Because real users are human, frail, imperfect and subject to many, many pressures.
Re:Why has no one taken this thread seriously... (Score:4, Insightful)
Now there are plenty of circumstances where standardization is called for...
I'm for it too. I don't know how old you are, but in my youth I spent a great deal of time building and troubleshooting 8086 systems. One of the biggest issues those days was figuring out which direction something was supposed to be plugged in. Connectors weren't keyed! A 24 pin connector was 2 rows of 12 pins and it could be plugged in either way.
Most external connectors were keyed (D-Sub connectors) but internal ribbon connectors, SIPP memory, and even processors could be plugged in the wrong way. If you were lucky, the manufacturer put a silk screened arrow pointing at pin 1, but that was most often not the case.
Standardizing tubing, or even standardizing tube labeling would be very helpful. Tracing lines might not be an option, why not mark them upon insertion?
I've been in both circumstances running data lines. I would much rather be involved in a job where each line was marked on both ends prior to installation. The alternative is a nightmare that at best takes forever and at worst, an eternity. I can't imagine being a nurse with a crucial medicine in hand tracing tubes.
You're really most sincerely wrong (Score:5, Insightful)
You're so wrong it's a good educational lesson to show why you're wrong.
Any nurse who does something like this is purely incompetent. I know several RNs and talk to a few on a daily basis. It is a somewhat stressful and fast-paced job, but you cannot ethically exceed your working pace. Every nurse should physically trace each tube to its receptacle. If there are two tubes in the vicinity but not even in proximity, extra care should be taken to trace the tube tactilely.
I deal with nurses too, particularly on safety issues. I also deal with government and civilian safety experts, and you're being unfair to them.
You display a fundamental misunderstanding of safety engineering.
You raise some important issues, but you've come to the completely wrong conclusion. Your political bias leads you to depend on "personal responsibility." Engineers have found that depending on "personal responsibility" is exactly what leads to disaster.
In the history of American engineering and industrial development, government "bureaucrats" have done a good job, often better than the industry they're regulating. If you want to see an unregulated pharmaceutical industry, go to China, where the free-market suppliers made drugs like heparin, cough syrup and infant formula that killed people. U.S. government regulators are responsible for dramatically improving the safety of the medical, airline, auto and electrical products industry, to name 4 that I'm familiar with. Even people in the regulated industries know this.
Think of these tubes. Engineers talk about an accident chain -- this includes mechanical factors and human factors. Every step of the chain has to fail for an accident to occur. If you interrupt one step, you stop an accident. You can tell nurses to trace tubes and lecture them about personal responsibility. But according to Murphy's law (the real Murphy's law, not the joke), if there is more than one way to do a job, and one way will end in disaster, then eventually somebody will do it the wrong way. The point is that if you depend on human action -- personal responsibility -- you'll have an accident. If you instead design mechanical fail-safe features, you won't have an accident. My question for you is: Do you want accidents or not?
As the TFA said:
“Nurses should not have to work in an environment where it is even possible to make that kind of mistake,” said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. “The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death.”
One nurse told me, "Have you ever been in an operating room?" There are thousands of devices, all of them with safety labeling, most of them with something that can go wrong. It's not humanly possible to check a thousand devices before each operation. You're asking people to do the impossible. If you demand "personal responsibility," you will have accidents. Do you want accidents or not?
What you can do is standard, textbook safety management. Anesthesiologists were having a lot of problems, patients dying, malpractice suits, etc. They adopted accident-prevention methods used by the airline industry. Government studies identified certain design features of aircraft cockpits as responsible for crashes -- for example, cockpit instruments and controls weren't standardized, so pilots would pull the wrong lever. The government ordered them to be standardized. Those crashes stopped.
Anesthesiologists had the same problem. They worked at different hospitals, with different equipment, and that caused mistakes. They standardized equipment, mistakes went down, fatalities went down, insurance premiums went down.
This shows that government can work. At the end of World War II, flying was an adventurous activity limited to people who were willing to risk their lives. T
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Yes, indeed, that is how this is supposed to work. Those are the rules. You don't know how very relieved I am to know that if I ever get killed by this sort of human error someone has assigned responsibility right where it belongs!
OTOH, you'll never see me successfully hooking up a CO2 regulator unto a nitrogen tank or a hel
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"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.
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Wait, they're supposed to be connected in series? My tubes are connected in parallel.
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Well, you'd think so. People would avoid hospitals that make a lot of mistakes like this, so as long as there is competition in the hospital market, then there is no need to regulate hospitals. The ones that kill people by accident will go out of business due to lack of customers (or they'll need to compete by offering their less-good services at a cheaper price -- this is the optimal solution, since then the wealthy would still get excellent medica
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That's one of the points I was trying to make (see the line further below about all of us having perfect information on the risks/level of service/price). Free Market Ideologues often forget that actual markets can only approach the behavior of ideal free markets whe
Thinking out of the box (Score:5, Insightful)
Re:Thinking out of the box (Score:5, Insightful)
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:4, Funny)
Nah, women are rarely colorblind.
<whispers in background>
Wait, there male nurses now? When did that happen?
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: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.
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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.
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.
Re:Thinking out of the box (Score:5, Insightful)
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...
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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.
Re:Thinking out of the box (Score:4, Insightful)
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: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.
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beacause (Score:3, Insightful)
"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 !
Color codes? Different connections? (Score:4, Insightful)
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.
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Man, hyperbole is so hard to spot these days!
Lawsuits (Score:2)
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
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.
Poka-Yoke (Score:4, Insightful)
Sounds like media fishing for a story (Score:5, Insightful)
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.
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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)
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.
Parallels with computer cabling (Score:4, Insightful)
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.
Re:Parallels with computer cabling (Score:5, Insightful)
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.
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.
Re: (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 plu
It makes sense (Score:2)
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
If filling stations can do it... (Score:2, Insightful)
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)
Re: (Score:3, Funny)
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.
Pun potential detected (Score:3, Funny)
Hmmm I wonder if this Dr. Robert Smith fellow has... The Cure... to such problems...?
Is the alternative better then? (Score:2)
It's not all downside. (Score:5, Insightful)
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.
They need an independent commission (Score:3, Insightful)
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.
Re: (Score:2)
I think colour coding alone would be enough, and way more cost effective than having different types of tubes for everything. Well apart from for the male nurses, who are far more likely to be colour blind..
Re:How about (Score:5, Insightful)
Unfortunately, the FTA says that some companies have internally consistent color codings, but other companies have pioneered their own color coding scheme. Even if the industry came together on a color coding standard, there would still be problems. The most obvious are color-blind nurses and doctors mistakenly connecting the wrong colors and accidental connections. Then there's the problem of internal consistency with colors. There's a reason Pantone is still in business. In my factory red comes out pretty close to Pantone 200. Due to differences in materials, production, dye quality, etc. your red comes out closer to Pantone 186. Both of those are pretty red, but next to each-other they don't look anything alike.
The simplest way to prevent this problem is what the OP suggests. Make the tubes physically incompatible and add a color code to simplify grabbing the right one. Even if the care-giver nabs the wrong tube, it won't be possible for them to connect it up.
I'm actually a little shocked to hear that this problem hasn't already been fixed. I suppose it has to do with the lengthy application and approval process for medical devices. Changing the ends or adding color probably requires an entirely new review by the FDA or some such agency.
Re: (Score:2)
Theres also the issue of colour affecting the look of the stuff being moved. A reddish tube might make someone think
there was blood in another fluid. It would have to be transparent enough to see the liquid inside clearly.
Stripes of colour along a tube might not be seen.
I suggest they invest in the no-kink spiral stuff that case modders use in watercooled PCs.
Wouldn't you visit a hospital more if all the drips had a glow under UV light?
Re: (Score:2)
Theres also the issue of colour affecting the look of the stuff being moved. A reddish tube might make someone think there was blood in another fluid.
You could have coloured bands round a tube, with the connectors also being colloured.
Re: (Score:2)
I'm actually a little shocked to hear that this problem hasn't already been fixed
It doesn't surprise me. Medicine hasn't taken on process definition the way most other industries have. I doubt most medical environments would qualify for ISO9001, let alone anything more prescriptive.
Case in point, when my wife was in hospital after giving birth to our son she sat up to breastfeed and started to slip off the chair she was in. Because she was recovering from a C-section she was unable to lift herself up so she pressed the call button for a nurse. Nobody came. Different nurses no doubt walk
Re: (Score:3, Insightful)
What? Sure they have, moreso than most industries. The problems are (1) process compliance; (2) insane process environment; (3) high cost of qualified staff. You KNOW the hospital has a process defined for responding to patient requests for aid via the call button.
How many nurses did they have in the ma
Re: (Score:2)
Being color-blind doesn't mean what you think. Red-green color-blindness doesn't mean you can't tell the difference between a red light and a green light, or between a stop sign and grass.
Besides, there's no reason why a 2-color band can't be used. White-Red-Orange-Yellow-Green-Blue-Black gives 7 colors. So, you'd have 7 1-color bands, 6+5+4+3+2+1 (21) two-color bands, for a total of 28 combinations. That should be more than enough to start with.
Re: (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: (Score:3, Insightful)
But those pictures are designed for people with normal vision to get an idea of colour blindness, not for colour blind people to get an idea of colour blindness. To accurately portray colour blindness to you, they just need to show a normal chromatic scale..
Re:How about (Score:5, Funny)
And a silver band means 10 percent tolerance, and gold means 5!
Re: (Score:3, Insightful)
You're worried about the expense of using different types of tubing and connectors? Here in the US, where you might pay $50 for an aspirin, and $1200 for a common, very standard blood test that actually costs about $15 in lab costs, I don't think the connectors are going to be the problem.
By the way, the second example of the $1200 blood test, comes from personal experience.
At least
Re: (Score:3, Insightful)
Injury is the trauma I wrote about. It can be a hit to the sternum by a steering wheel or a 50 cal bullet to the calf. (Yes, a 50 cal to the calf will cause cardiac arrest a day or two later)
Going into shock won't cause the cardiac arrest itself. The arrest is usually caused by something else cascading--perhaps blood pressure dropping.
The issue is that people think the disease is the arrest. It's not. The other aspects of life (poor eating, putting yourself into the path of a bullet) are the issue. Th
Re: (Score:3, Insightful)
Re: (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
Re: (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: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:How about (Score:5, Insightful)
stock a huge spool and cut it in place ???
are you fucking insane ? hospitals are not datacenters, dude. those tubes need to sterilized in well equiped facilities, then wrapped in sterile bags that can only be opened when it's time to use.
do their job and not make mistakes,
ok, now i know you're a troll. obviously you never worked anywhere where you could be subject to enourmous pressures, having only a split second to make a vital decision. if you had, you'd know that under those circumstances, even the best trained professional can make mistakes. nurses are human beings, not machines.
Re: (Score:3, Insightful)
I can just imagine the scenario now
Unfortunately for your imagination, it has decided on a scenario that has been the actual case for decades: gas couplings in the OR are in fact unique so, for example, oxygen and anesthesia cannot be confused with each other (this is the case in Canada, at least).
And strangely enough the disaster you fantasize about hasn't happened.
Maybe you're just a fearful conservative making shit up to save yourself the dreadful pain of dealing with change.
Re: (Score:3, Insightful)
You overestimate the cost and underestimate the savings. We already have deliberately incompatible connections in many, many other places where the consequences are less dire, and, yes, it is worth it. Color coding is good, but not enough. For instance, a smaller diameter nozzle is used for unleaded gas than for leaded gas. This is to prevent people from accidentally destroying their catalytic converters by making it difficult to mistakenly fill their unleaded only car with leaded gas, as the larger noz
Re: (Score:2)
And since the industry won't take care of it, I agree the government needs to step in and make them take care of it, though I'm not sure if permanent regulation (temporary until it's SOP should be good enough) is the answer.
Re: (Score:2)
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.
Re: (Score:2)
The interconnect keying can be designed to allow master keys. So that a cap will attach and lock to any tube, but when mating tube ends and to other tubes or tube-attached equipment, only the like kind will mate.
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: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:Ummm Personal responsibility? (Score:5, Insightful)
Personal responsibility goes a long way in every job from auto mechanic to jet pilot, but redundancies help everybody. I rather like that my radiator cap is labeled differently than my oil cap. Sure it's my responsibility to make sure I put the right fluid in the right hole, but having a little bit of labeling sure saves me some greif. I also bet that pilots enjoy having all the automated warnings built in. Sure, a pilot's job is to monitor the gauges and double and triple check that everything is working right, but when the proximity alarm goes off you can bet he's pretty happy it was there. And if you happen to be on the plane, you're probably pretty happy that it's there as well.
Nurses have hard jobs that require lots of thinking, physical labor and are frequently over worked. A little redundancy that adds minimal material cost to the appliances is not only a nice feature for them, but a nice feature for the person they're working on.
Re: (Score:3, Insightful)
It's so much easier. Problem solved.
To fail is human. Even the best nurse will make mistakes after running around for 20 straight hours of work in an overcrowded, understaffed hospital.
Re: (Score:2)
Personal responsibility is a concept that seems reasonable but is basically idiotic when put into the context of the Real World. It's the same as thinking that no one will lose their job if you remove all social safety nets.
Mistakes _WILL_ happen, always, even with several layers of security protocols. That is reality and we need to design stuff with reality in mind. Just color coding or text labeling doesn't take things far enough, as those are measures that assume the nurse isn't distracted by e.g. an ann
Re:Ummm Personal responsibility? (Score:5, Insightful)
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?
"look, I -understand- your heart has stopped, sir, but if you'll just be patient with me--heh, "patient"--I'll trace these tubes back to...the...appropriate bits of--OK, that's the one..."
Personal responsibility is a wonderful thing, but nurses a) often don't have the luxury of time, and b) like other human beings, occasionally make mistakes. Further, nurses don't have the luxury of an Undo command, and very, very slight errors can and often are fatal.
Re:Ummm Personal responsibility? (Score:4, Insightful)
Re: (Score:2, Insightful)
Boiling it down to personal responsibility is nice and all....until it turns out that your spouse or child is one who dies because their nurse screwed up. Sure, you can sue them, get them fired, or maybe even thrown in jail in a few rare cases, but I doubt any of that will be comforting enough to make up for your loss.
Re: (Score:2)
Your the one human on this planet who has never made a stupid mistake, right?
Re:Ummm Personal responsibility? (Score:5, Insightful)
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?
I'm guessing you are under 30 and/or have never worked on anything mission-critical. You've also never taken a statistics course, or if you have you have failed to apply its lessons.
It is "so hard" because nurses do this dozens of times a day to patients who change on a regular basis, and both thinking and remembering are hard. If a nurse has a 0.1% failure rate--when was the last time you got 99.9% on an exam, by the way?--they will do the wrong thing a few times a year. Most of those wrong things will be harmless. If they have a 0.001% failure rate they will still err every decade or so.
Anyone who knows anything about the actual, empirically verifiable nature of human beings, rather than some pulp fiction fantasy, knows that humans make mistakes. It is what we do. Intelligent people respond to that uncontroversial fact by building systems that make mistakes more difficult. Gibbering idiots thump their chests and witter on about personal responsibility.
Re: (Score:3, Insightful)
Good point. And let me add, consider the fact that hospitals can have hundreds of nurses. If the average nurse makes an error only once a decade, then 100 nurses will average 10 errors each year. Error prevention systems are a good thing.
Re:Ummm Personal responsibility? (Score:5, Insightful)
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.
I would like to reply to this instead of marking it down as "-10 clueless" because people should read why it is clueless.
The goal here is not to find someone to blame when a patient dies, the goal is to reduce the likelihood of a patient dying in the first place. The goal here is not to find ways how to make a nurse take more time looking after a patient in order to do a proper job, because that only allows them to be pressured into rushing things when they have to meet goals like looking after so many people per hour.
You are going on about the personal responsibility of the nurse, what about the personal responsibility of their f***ing manager? One of the things a manager does is goal setting, and a very important aspect is not to set conflicting goals and arrange things so that a nurse trying to meet one goal will be on their way to meet the others. You are trying to make speed + safety contradictory goals, a sure recipe for disaster. Safety is best handled in such a way that it is unavoidable, not in such a way that it can be done away with to meet other goals.
Another principle that has served me very well while driving a car: People make mistakes. Accept that as a fact, no matter how careful they are, people make mistakes. In road traffic, mistakes only lead to accidents of other drivers don't manage to react to mistakes. So you do two things: Drive so that others can react to your mistakes and avoid accidents for you, and drive expecting others to make mistakes and fix them for them. (This also makes it a lot less stressful, when you take all the stupid things people do as just normal things and don't get excited about them).
Re:Ummm Personal responsibility? (Score:5, Funny)
I've met girls with that kind of attitude to something potentially risky - "Just be careful".
Most of those girls are now mothers.
Re:Long nursing shifts (Score:5, Insightful)
It's unfortunate, but the medical industry is at odds with reality when it comes to human performance. They claim, no, swear, -- and I have first-hand anecdotes from top-notch physicians and surgeons -- that long shifts are somehow necessary for "continuity of care" and other such buzzwords. Somehow they believe they are superhumans. Nobody has ever trained them how to effectively communicate patient state to their replacements. It should be a semi-formalized process, that is being taught, and part of the licensing exam curricula. Pilots and nuclear plant operators are trained for it, why the heck doctors are nurses are above it all I don't know.
10-12 hour shifts are effed up.
Re:Long nursing shifts (Score:4, Insightful)
Nobody has ever trained them how to effectively communicate patient state to their replacements.
Communication is the one thing that is harder for humans than thinking and remembering. The most important people management lesson I ever learned was playing the "Telephone" game as a kid: there's about 50% information loss on any transmission of even the simplest message.
A quick look at the documentation for your current project will suggest the same thing.
It is not surprising, therefore, that the leading cause of iatrogenic disease is mis-communication, not mistakes made by tired staff.
That said, the solution to the problem is overlapping shifts: nine hour shifts with an hour overlap, so the evening shift has an hour with the day shift still on, and so on. This--depth of time--is one of the most critical factors in effective communciation.
Re:Long nursing shifts (Score:4, Insightful)
I agree -- this is so critical that it not only should be part of licensing curricula, the institution-wide communication plan should be part of medical institution licensing as well. You need a license to run a hospital, with occasional checks for certain things, so it'd be easy to enforce it.
Unfortunately, it's not part of the culture, and it seems that otherwise rational top-notch doctors seem not to have a clue about it at all. Heck, they get all worked up against it whenever I mention the topic.
I also think that hospital f-ups should be reported and published the same as major transportation mishaps. Otherwise no one will learn any lessons, because none are to be easily found. A lot of malpractice and substandard care suits end up with a settlement with no admission of guilt -- and all of the details are not public. So even if I were to, say, prepare a course curriculum for doctors/medical administrators, there is little in the way of well researched examples to give. Compare that to teaching pilots: you could go over the accident reports forever, it seems.
Re:Then where will nurses work? (Score:5, Insightful)
Pilots have extensive training and "know what they are doing", yet checklists are part of standard safety policies. Why? Because checklists save lives.
Does it matter if only 1 person a year dies from having a stupid mistake, if it happens to *you*, while you are having some silly routine procedure happen? Do you want to be the one who dies having an MRI because someone forgot to ask if you had any metal implants?
We could just say that malpractice judgments will incent people to do the right thing.. hey, wait...
maybe it is!
Re:It's society's fault! (Score:4, Insightful)
Just saying "pay attention" isn't enough. No-one, not you, certainly not me, can attend exactly to what they're doing for every second of every minute of every day.