Recently in the NYTimes, an interesting look into the simplest of medical errors: connecting the wrong tube to a patient. Devastated families and regulators ask, why should it even be possible to connect feeding tube contents to an IV? Or IV fluids to a nasal O2 cannula?
Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible — just as connections to piped hospital oxygen, medical air, nitrous oxide and vacuum are incompatible with each other.
… action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.
Hospitals, tube manufacturers, regulators and standards groups all point fingers at one another to explain the delay.
Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.
Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences.
“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.”
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 Julie Thao, a nurse at St. Mary’s Hospital in Madison, Wis., mistakenly put a spinal anesthetic into a vein, killing 16-year-old Jasmine Gant, who was giving birth.
Amazing stuff. The article goes into more detail on the FDA device approval process, if that sort of thing is as interesting to you as it is to us…
More from a recent FDA warning about oral med capsules being given IV…
