Look-Alike Tubes Lead To Hospital Deaths

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.

Comments

Its not just the internet

[maroberts]

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

Re:Its not just the internet

[DWMorse]

This problem is tubular. Dude.

Re:Its not just the internet

[mcgrew]

"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.

Re:Its not just the internet

[PopeRatzo]

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.

Re:Its not just the internet

[bsdaemonaut]

I guess the same idiot that invented mass production? Seriously these are tubes we are talking about, not electrical adapters. I get what TFA is saying and it sounds like it would be a good idea to go that way.. but..

"Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein." .. that's just idiocy plain and simple, no amount of manufacturing is going to keep stupid people from doing stupid things. Plus, I have to ask myself.. what happens when you need an intravenous tube and the nurse on duty can only locate feeding tubes? Precious seconds could be lost while a patient is in critical condition.

Re:Its not just the internet

[Anonymous Coward]

Whooossshhh... That's why people is dying... they are connecting them to the Internet instead to the IV.

Re:Its not just the internet

[Red Flayer]

Isn't the free market supposed to solve issues like this?

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 medical care while the poor could still afford *some kind* of medical care, even if it kills them).

The only reason we don't have effective competition in the hospital market is because of government interference in the market -- through subsidies and regulatory barriers to entry, the GOVERNMENT has granted legal monopolies to hospitals, so we don't have a real choice of hospitals to go to. Imagine if the government stopped interfering in the hospital market... we'd all have ten or twelve hospitals to choose from, with varying levels of risk and price, that we'd be perfectly informed of. The wost hopsitals would go out of business, which is fine, since we'd have a dozen other hospitals to choose from. Everyone wins!

/end FreeMarketIdealogueIdiot

How did I do? Does that just about sum up the FMII position on regulation?

Re:Its not just the internet

[gmack]

Hospitals keep extras of everything and put them in standard places. I fail to see how this could ever be a problem

Re:Its not just the internet

[nbauman]

/end FreeMarketIdealogueIdiot

How did I do? Does that just about sum up the FMII position on regulation?

Pretty good. You had me going there for a while.

Re:Its not just the internet

[Anonymous Coward]

. The ones that kill people by accident will go out of business due to lack of customers"

Wrong. The ones who kill people and have money simple enter in agreement with their "costumers" not to go public .RTFA "(She lived in a small Kansas town, but because of a legal settlement with the hospital, her mother would not identify it.) "

"since then the wealthy would still get excellent medical care while the poor could still afford *some kind* of medical care, even if it kills them"

I can't argue with that. I'm one of those who thinks health care should be equal to everyone. We are talking about lives here, but it's difficult to argue with someone who puts a price on people's lifes. If it was up just to the market there's no need of heath care for the poor.

Re:Its not just the internet

[Red Flayer]

Wrong. The ones who kill people and have money simple enter in agreement with their "costumers" not to go public .RTFA "(She lived in a small Kansas town, but because of a legal settlement with the hospital, her mother would not identify it.) "

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 when there is perfect information symmetry. This breaks the model they base their beliefs on. Instead they talk about regulatory barriers to entry, quickly dismissing natural barriers to entry (like huge equipment costs) and the other requirements of an ideal free market.

I can't argue with that. I'm one of those who thinks health care should be equal to everyone. We are talking about lives here, but it's difficult to argue with someone who puts a price on people's lifes. If it was up just to the market there's no need of heath care for the poor.

Well, yes and no. There is *some* need for healthcare for the poor... marginal workers are not infinite, after all. Plus we need to factor in things like herd immunity, which is dependent on immunization being provided to almost everyone, especially the dirty poor who live packed together in hovels.

Oh sorry there, I was slipping into FreeMarketIdeologueIdiot again.

My real position: It's just too damn expensive to provide the best-level care for everyone. Everyone should have the right to a decent level of healthcare; those who can afford to pay more should not be prevented from getting better care (a la the current situation, just with a single-payer system for the basic level of care). There's no reason the wealthy shouldn't be able to go to an exclusive, expensive provider at their own expense, or charities could not provide the same for regular or poor people. That's my only fear with a single-payer system -- the best care might not be available to those who can afford it.

Re:Its not just the internet

[clang_jangle]

My tubes were tied years ago, I guess so they can't connect anything to them.

Re:Its not just the internet

[fractoid]

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

Am I the only one who, seeing "look-alike tubes", thought "redtube, xtube, yourpron..."?

I guess, come to think of it, the internet really IS a series of 'tubes'... O.o

Re:Its not just the internet

[Anonymous Coward]

You make two points and they're both flawed. The first, that "no amount of manufacturing is going to keep stupid people from doing stupid things" might have some basis in truth, but we're talking about simply putting an adaptor on the end of a tube so it can only go to the right connector. It would cost pennies and it absolutely would have prevented the screw up in this case and many more (and before you throw around accusations of stupidity, try working four 14 hour shifts, get home on friday evening at 8, bed at 9.30 then getting called out at 12am to a 6 hour operation and see if you manage to make it through that without making a mistake, if you keep that up for 10 years without making a mistake we'll judge you fit to comment on what is simply an overworked human making a mistake and what is stupidity). Secondly, as gmack already said, hospitals keep spares of these things, and they have systems in place to ensure you know exactly where to find what you need when you need it and that replacements are ordered before they are needed. If you run out of tubes it's a failure to order them and the way you deal with that is you put in place a system to ensure they are ordered early and that stock is frequently checked, you don't just replace them with generic tubes - that doesn't solve the problem if your ordering system is screwed up, unless you think a doctor can whip the feeding tube out of one patient's stomach and use it to do an emergency transfusion on another patient.

Re:Its not just the internet

[Anonymous Coward]

It's just too damn expensive to provide the best-level care for everyone

I agree. But I'm not talking about the best-level.
I live i a small country that has an (almoust) free health care system. We also have a GDP/per capita of about $22,000 witch is less than half of the USA. And you know what. It works. We have a very decent quality( one of the best in the world in public health care systems).

We still have private hospitals, but you know what. The middle class and some higher classes actually prefers the quality of the public services- It's so good in fact that the President and Prime Ministers use it when they have health problems.

Here we are talking about a public health system with a country that has a GDP/per capita half the USA, and we still have decent health care. So please don't tell me that is too expensive to
provide a decent quality health care system to everyone, especially in US. Perhaps if you eliminated the profit you could really spend money on things that are needed. That is what a public health care system does. It eliminates the need of profit since everyone pays for their health-care on their taxes, so the costs are a lot less.

Re:Its not just the internet

[pandaman9000]

And new regulations cost resources. People will still die to idiocy/understaffing. Why don't you focus your ire on the benefits of paying nurses better AND increasing staffing. If nursing pays better, more people choose that route. More pay also means you can have higher standards. More staffing means less overtime hours. Less overtime offsets some of the increase to base pay.

Everyone wins.

Re:Its not just the internet

[Red Flayer]

Here we are talking about a public health system with a country that has a GDP/per capita half the USA, and we still have decent health care. So please don't tell me that is too expensive to provide a decent quality health care system to everyone, especially in US.

I didn't say that. I said it's impossible to provide the *best-level* care for everyone.

I think also that GDP/capita is a misleading metric by which to compare health care costs... since it is very likely that in your country doctors, nurses, nurses aides, custodial staff, etc all get paid less than in the US. Eliminating the profit is one thing that is necessary, IMO -- especially for insurance companies. But we can't get away from the fact that wages are very high here, and that the US is a litigious society -- meaning not only do we have huge malpractice insurance costs, we have lots of redundant/unnecessary care that we must pay for to protect our care providers from being sued.

Re:Its not just the internet

[Nadaka]

I thought the point of tying the tubes was so that you COULD connect anything to them?

Re:Its not just the internet

[Anonymous Coward]

Free Market Ideologues often forget that actual markets can only approach the behavior of ideal free markets when there is perfect information symmetry. This breaks the model they base their beliefs on. Instead they talk about regulatory barriers to entry, quickly dismissing natural barriers to entry (like huge equipment costs) and the other requirements of an ideal free market.

Although you display a kludgy familiarity with the names of concepts - free market, perfect market (not ideal) - you do not understand how they interact. From the wiki:

A free market is not to be confused with a perfect market where individuals have perfect information and there is perfect competition.

Please refrain from posting on markets until you learn the basics.

Re:Its not just the internet

[Red Flayer]

What are you blabbering on about? The terms "ideal free market" and "perfect market" are both used, "perfect market" is a more recent name for the same thing, largely because ignoramuses kept conflating ideal free markets with markets free from regulation. Why not consult a real source instead of wikipedia (which, by the way, you incorrectly refer to as "the wiki" -- that's bad juju)?

I could pull out and dust off my old econ textbooks and show you. Or I could just refer you to one of the economists most often cited by free-market ideologies: Milton Friedman (you might have heard of him, he won a Nobel Prize). Friedman refers to it as an "ideal free market", as does Krugman (also a Nobel Prize winner), as have many economists when speaking about general equilibrium theory.

In short, stuff it. You're obviously the one without a background in economics, or you would have known this to be the case.

Kindly refrain from posting about others' supposed ignorance when posting blind on the topic, as you just did.

Re:Its not just the internet

[Coren22]

How many tube types do they use? If each tube is different, they now need to multiply their storage space to have a place for each kind of tube they need, and in a pinch can't just grab a tube, now they need to worry that they grab the right kind of tube.

Re:Its not just the internet

[clang_jangle]

What, to my tubes?! You're doing it wrong...

Re:Its not just the internet

[Anonymous Coward]

I wish that eliminating some of the riff-raff on the Internet was as easy as injecting some spinal anesthetic into my cable modem.

Re:Its not just the internet

[Anonymous Coward]

In an ideal free market resting on private property, no individual can coerce any other, all cooperation is voluntary, all parties to such cooperation benefit or they need not participate. There are no values, no "social" responsibilities in any sense other than the shared values and responsibilities of individuals. Society is a collection of individuals and of the various groups they voluntarily form. link

If you have a reference that shows Friedman confusing "ideal free markets" (or free markets as "ideal" is a somewhat needless qualifier in this context) with "perfect information symmetry" then please share it. I'll grant you a few days to dust off your voluminous references.

Re:Its not just the internet

[Red Flayer]

I'm not going to bother doing that for a trolling A.C.

Re:Its not just the internet

[Anonymous Coward]

There is no trolling here. You won't admit that you are wrong. I feel your pain but let's not live in a fantasy world here. You have fallen for a trap to promote socialism. The "perfect market" (including information symmetry) is a set of conditions which no market will reach (free or otherwise) and is the justification for government intervention where it would otherwise not be necessary.

Successive mathematical torturing has outlined an extensive list of unlikely conditions required to demonstrate general market efficiency. Mark Blaug has nicely summarized a partial inventory: "perfectly rational, omniscient, identical consumers; zero transaction costs; complete markets for all time-stated claims for all conceivable contingent events, no trading at disequilibrium prices; no radical, incalculable uncertainty...; only linearly homogenous production functions; no technical progress requiring capital investment, etc" (1997, p. 5)... link

Here is an example of how the argument is exercised:

Capitalism is fine and dandy in theory. If you have perfect information and a perfect market and every single person has identical opportunities then it's a great system. People who work hard will achieve the most and people who don't work hard will struggle to get by. It's a perfect carrot/stick combo.

Then you get to the flaws. There's no such thing as a perfect market. There's no such thing as perfect information. And the differences in true opportunity between those born rich and those born poor are staggering. link

SINCE YOU ARE SUCH A DIPSHIT AND CAN'T DUST OFF YOUR BOOKS AS YOU PROMISED (BECAUSE THEY DON'T SUPPORT YOUR BS), I WILL MAKE A POINT OF POSTING A LINK TO THIS WHEN YOU POST ELSEWHERE. LET THE WORLD, YOUR EMPLOYERS, FAMILY, ETC, KNOW THAT THE *RED FLAYER* IS A DUMBFUCK!

Re:Its not just the internet

[Red Flayer]

Oooooh... anonymous stalker on slashdot! Yay! You're not the first one, and you won't be the last.

Take your meds or grow up.

So what if I was wrong? Is it now your life's work to point out that Someone is wrong on the internets?

I was wrong. There. Are you fulfilled now? Will you be able to sleep at night, knowing that I, Red Flayer, admitted on slashdot that I made a mistake when posting on slashdot? Does it make you happy? Did you just come a little bit, in your pants, just now? Do you even wear pants? Do they allow you to wear them in your institution, or do you have to wear hospital gowns?

Re:Its not just the internet

[Red Flayer]

And now for a serious response to your post:

There is no trolling here. You won't admit that you are wrong. I feel your pain but let's not live in a fantasy world here.

The tone of your posts suggest you're trolling. Your demands, etc.

You have fallen for a trap to promote socialism. The "perfect market" (including information symmetry) is a set of conditions which no market will reach (free or otherwise) and is the justification for government intervention where it would otherwise not be necessary.

And you've let yourself be deluded that the alternative is optimal. An unregulated market trends to a noncompetitive state. You've fallen in to a trap designed by the extremely wealthy to ensure that you support the policies that are best for *them*. Unless you are one of them, in which case, why are you even on slashdot, except to con others into believing that claptrap?

Here is an example of how the argument is exercised:

Capitalism is fine and dandy in theory. If you have perfect information and a perfect market and every single person has identical opportunities then it's a great system. People who work hard will achieve the most and people who don't work hard will struggle to get by. It's a perfect carrot/stick combo.

Then you get to the flaws. There's no such thing as a perfect market. There's no such thing as perfect information. And the differences in true opportunity between those born rich and those born poor are staggering.

Wait, are you trying to claim that is the position I hold? Or that I'm swayed by that position?

I'll just cut to the chase here to get you off your rant: Capitalism works, it seems to be the best option we have. However, regulation is required to promote and maintain competition, and to account for externialities to transactions, and to ensure access to information in markets.

These regulations do not constitute Socialism, which you may be dismayed to find out. I find it laughable that you claim that there is some plot to trap people into promoting socialism. There are, indeed, plots to trap people into thinking unregulated capitalism is the best thing for them, which you have fallen for. The actions of the Koch family are one example... they've spent millions upon millions to convince people that the policies best for the Koch family are the policies best for the everyman.

But go ahead, let yourself be deceived. I know I'm not going to make any headway against your misguided positions, you're far too off your rocker.

SINCE YOU ARE SUCH A DIPSHIT AND CAN'T DUST OFF YOUR BOOKS AS YOU PROMISED (BECAUSE THEY DON'T SUPPORT YOUR BS), I WILL MAKE A POINT OF POSTING A LINK TO THIS WHEN YOU POST ELSEWHERE. LET THE WORLD, YOUR EMPLOYERS, FAMILY, ETC, KNOW THAT THE *RED FLAYER* IS A DUMBFUCK!

Be an adult and log in when you write things like that. And the all-caps, and bolding? Makes you look certifiably insane. Which you may be.

How about

[Anonymous Coward]

Color codes and making it impossible for two of the wrong type of 'tubes' to ever be connected. size/shape/connector...

Send me my check now...

Re:How about

[somersault]

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

[wjousts]

And surely different color tubes (and/or sizes/connectors) would make industry happy. More sales of medical tubing if you can't interchange them.

Re:How about

[txoof]

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:How about

[kenh]

By requiring that every connection/tube be a different color/size, you've now made medical care even more expensive than it already is - hospitals will be forced to stock all manner of spare parts, in sufficient qty for all possible applications - they will no longer be able to stock a huge spool of bulk tubing and cut it down for the application required... Sounds like a trivial expense increase right? But the hospital will have to have somewhere to store all these unique parts (build a storage facility, for example), they'll have to man it 24x7 (that's a minimum of 4 full time employees), plus have some way of inventorying and distributing the unique parts to all places in the hospital (a group of orderlies with carts, say another 10-15 full time jobs for a regular sized hospital, again to allow for 24x7 coverage), and let's not forget the increased expense of each specialty part when compared with the cost of a length of tubing cut off a huge spool of PVC medical-grade tubing.

But hey, we'll have lowered the bar on the nurse's job - you know who nurses are, right? They are the ones that went to college for four years, then went on for a nursing certificate and worked for months/year to learn how to do their job and not make mistakes, but heck, we can't hold them responsible for actually paying attention and doing the right thing...

I can just imagine the scenario now - "Sorry, we'll have to reschedule your open-heart surgery because we've run out of magenta anesthesia tubing with the square fittings, and trust me, you're gonna want anesthesia for that operation - we sent Jimmy over to the hospital on the other side of town to see if they can spare an appropriate tube..."

Re:How about

[click2005]

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:How about

[PopeRatzo]

I think colour coding alone would be enough, and way more cost effective than having different types of tubes for everything.

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 in this country, nothing in health care costs is tied to anything like reality. For all we know, the insurance companies might claim that having hospitals use different types of tubing will triple health care costs across the board.

Re:How about

[MichaelSmith]

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 walked past the room and assumed that responding was Somebody Elses Problem. My wife eventually called the hospital from an outside line, got reception and they sent somebody up to help her.

One of the QA managers where I work had a similar experience when we was in hospital.

I think the reason is that doctors and nurses think they know everything which they need to know and no outsiders are going to tell them anything different.

Re:How about

[C0vardeAn0nim0]

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:How about

[Chrisq]

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:How about

[tomhudson]

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:How about

[radtea]

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:How about

[kenh]

'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.

Yeah, exactly - the FDA could change EVERY CONNECTOR on every medical device that uses tubing "tomorrow" (I assume you meant that metaphorically, not literally Dr. Smith), ignoring that changing each connector on, say, an air pipe, would require a recertification of the device. How many connecotrs in each hospital room would have to be changed? Doctor's office? Operating rooms? Ambulances? And how long would it take the industry to respond with retro-fit kits and sufficient inspectors to review all the work required, let alone the lead time needed to manufacture, distrubute and use all the new tubing required...

Re:How about

[kestasjk]

I love how the summary and focus here is on making the nurses and the industry happy ("nurses shouldn't have to work in an environment where this kind of mistake can be made"), yet no-one mentions the slightly disconcerting possibility for a patient of having a blood-pressure air-pump tube hooked into a blood vein..

Oh god that's horrible.. I'll have that in my mind whenever I get a drip put in now.

Re:How about

[glueball]

Don't worry. Based on my experience working in medicine, in the future you will not get a $50 aspirin or a $1200 lab test. You will see your GP who will tell you to go home, put down your cheeseburger, go for a walk, take your own aspirin and call him in the morning.

There are two things that work in medicine. Surgery and antibiotics. Everything else treats symptoms or confirms you need either surgery or antibiotics.

Re:How about

[somersault]

I dunno.. if you look at the protanopia and deuteranopia pics on the wiki page for colour blindness, they look pretty difficult to tell apart to me.

Re:How about

[Anonymous Coward]

And a silver band means 10 percent tolerance, and gold means 5!

Re:How about

[Ironhandx]

They already do this in(at least some, in newfoundland)hospitals in Canada. They had an issue with pink and red tubes that they wanted to use because the men couldn't tell them apart something like 70% of the time. So the pink tube is now green iirc.

Re:How about

[lattyware]

If I had mod points...

Re:How about

[digitalunity]

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

[oldspewey]

Or you could have unique patterns of dots and dashes running the length of the tube. Or you could repeatedly print the number "1" along the length of tube type 1, and the number "2" along the length of tube type 2. Or you could use letters of the alphabet. Or letters of the greek alphabet. Or you could make some tubes ridged and some tubes smooth.

There are literally dozens of ways to solve this problem. None of them are exactly brain surgery.

Re:How about

[IndustrialComplex]

I dunno.. if you look at the protanopia and deuteranopia pics on the wiki page for colour blindness, they look pretty difficult to tell apart to me.

I'm color-blind and those pics are nothing like what a color blind individual sees. The pictures look screwed up even to me.

Re:How about

[WCguru42]

All these are fine and dandy, but none of them has the elegance and nearly, I repeat, nearly idiot proof-ness of the OPs different connections concept, which I believe has and is used in various other industries to great success. This is not to say that the nurses themselves are idiots for missing the connections when all the tubes are identical but if you can make something strong against idiots its safe to say that educated people should be able to have even greater success.

Re:How about

[ErroneousBee]

Fungicide worked for me.

Re:How about

[oldspewey]

I'm okay with the idea of different connections, just as long as we don't let Sony anywhere near the scheme.

Re:How about

[Beorytis]

There are two things that work in medicine. Surgery and antibiotics.

No wonder there is so much unnecessary surgery and over-prescription of antibiotics. When the only tool you have is a hammer, every problem is a nail.

Re:How about

[elBart0]

What about validation?

The whole product development life cycles, as well as the IQ/OQ/PQ portion of validation with the required submissions to the FDA for new devices can not be compressed down to two weeks. Two months is a possibility, but you're also failing to account for the fact that cross company/ industry wide standards would have to be developed and approved prior to the creation of the new kits. That's a process that takes years in most industries.

Re:How about

[WCguru42]

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.

Forget the fact that there are numerous high stress situations for nurses, show me a person in any job that hasn't made a single mistake. No amount of prep work can eliminate error, it can only reduce it. This is why hospitals should (have started to?) use checklists for many if not all procedures. Checklists, while sometimes tedious and annoying, go a long way to reduce human error. The same would be true for different sized/ shaped connectors.

Re:How about

[bzipitidoo]

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 nozzle won't fit. (The other way around is no problem.) In the automotive and HVAC industries, they've learned that plugs which gather many electrical connections into one and can fit only one mate one way save money. Otherwise, people on the assembly line will miswire things. Mere color coding will not prevent that. The workers are always being pushed to increase production, to be faster, always faster, and mistakes will happen. Management has to relearn this lesson periodically when some new group comes aboard and immediately gets too cheap by eliminating those "expensive" plugs, often with a gratuitous declaration about what idiots the previous group was for missing such an obvious savings. Make the assembly line and field deal with individual wires. Makes the new management look good for a short time, until the problems start happening. The pennies they saved by eliminating plugs will be more than wiped out the moment a batch of miswired units makes it out of the factory and has to be recalled. If they can fix the units as the trains deliver them to dealers, it only costs a small fortune. If the miswired units make it all the way to customers, it costs a large fortune to fix. Even on those batches where no mistakes were made, it still causes problems in the field as the maintenance and repair people must deal with considerably more complexity. Consumer electronics manufacturers have also had to learn that it is best to make it as difficult as possible to make wrong connections. Unfortunately, they've clouded things by also using incompatibility nefariously, to lock customers in.

All that supposed extra expense you're decrying is not that much, and will be more than paid for the instant a mistake is prevented and a costly lawsuit is avoided. The US medical industry is too protected, and very backwards in this and quite a few other areas such as their laughable employment of IT. They're good at flashing the glitzy stuff like that hot new MRI or CAT scanner, but they fight the basics such as storing patient records in databases. They'll claim they can't do it because of HIPAA or the threat of lawsuits, and while there's something to that, they certainly could do more. Interesting that the summary blames the government for this. Other industries figured out it was worth doing. Didn't need government prodding.

Re:How about

[gnasher719]

I love how the summary and focus here is on making the nurses and the industry happy ("nurses shouldn't have to work in an environment where this kind of mistake can be made"), yet no-one mentions the slightly disconcerting possibility for a patient of having a blood-pressure air-pump tube hooked into a blood vein.

How is this about making the nurses and industry happy? If "nurses shouldn't have to work in an environment where this kind of mistake can be made" then it means patients are not in an environment where nurses can make this kind of mistake. Believe me, you and your relatives are much more unhappy when things go wrong than the nurse.

Re:How about

[bsdaemonaut]

Agreed, I've never seen a tube on a blood pressure pump that looks anything like an intravenous tube...

Re:How about

[natoochtoniket]

The gay and lesbian hospital association demands nothing less than 100 percent tolerance.

The G&L association even has the solution for color blindness. Six-color stripes, like the rainbow-flag, should be more than enough colors on each item so that even color blind people can tell them apart. Just make some of the stripes wide, and some narrow, like bar-codes.

This could be intuitive, to minimize the training: A wide red-stripe means it has something to do with blood. A wide green-stripe means it has something to do with oxygen. Blue for water. Purple for suction. etc.

Re:How about

[DrMaurer]

You do know there are pharmacists and their technicians on duty, right? Ones that already are responsible for categorizing and, in some cases, preparing such drugs and delivery systems.We can fix it, we have the technology. There is no excuse simply because a hospital "needs a few extra tubes around." They don't run out of this stuff, and if they do then the hospital (as an entity separate from the patient) can be in serious trouble. And the cost of the tubes are ephemeral compared with the labor costs of the people that are already there.

The number of drugs most hospitals have on-hand, at all times, is mind-boggling; you think a few non-interchangeable tubes is going to be a problem? I'm sorry, it's not a car junkyard, eh.

It's not that the nurses shouldn't make mistakes (they shouldn't, but they do, because they're frakking human), but it's about making the system now allow stupid mistakes like this.

Re:How about

[txoof]

Colored bands are a great solution for identifying things (like resistors, for example), but they still don't solve the problem of accidental connections. A tube that will not physically connect to another tube is a sure fired way to get someone's attention, especially if they're doing something wrong.

The engine of a car, or the motherboard of a PC are evidence that we've solved this problem several times. Even experienced people try to hook up PSUs backwards, or swap their spark-plug wires (which is one (and I know there are others!) reason they're different lengths). A keyed connector saves everybody some level of greif. It still won't turn off idiocy and keep you from breaking off mother board components, or shorting a spanner over the battery, but it helps and it's a cheap way to prevent expensive failure.

Re:How about

[digitalunity]

There doesn't necessarily need to be industry wide standards. If a major device manufacturer devised a scheme and put it on the market before anyone else, it would become the industry standard.

As far as validation, yes it can be very quick. DQ and 510k could be done by the devices company and the manufacturer would do the IQ/OQ/PQ. These could happen in parallel if there is some confidence that no modifications are necessary. Otherwise you just wasted a bunch of money.

It doesn't have to take years.

Re:How about

[Eraesr]

If a nurse is dumb enough to connect a spinal anesthetic to an intravenous drip, then the problem is larger than the tubes themselves.
I'm pretty sure that nurse Dumb would not pay attention and connect the blue to the red tube anyway.

Re:How about

[MMC Monster]

Errr... The tubes are pretty much incompatible with each other. You have to really try hard to get a BP cuff tube to fit into an intravenous line. And by try hard, I mean use a knife or scaple to reshape it.

As or intravenous vs. spinal... That's harder. It will certainly increase costs. How many lives will it save per year vs. how much would it cost?

Would you spend (a million dollars per life saved) per year? Well, yeah, probably. (I think the statistic is something like that for mamograms for women over 40 years old.) But what if the number's a lot more?

Re:How about

[poetmatt]

this is simple and correct, but why even go that far? Why not just get colored tape and put one around each tube, maybe even write a description with a pen? Wouldn't that work on a basic level?

Also yes, agreed, specific connectors for each.

problem solved. no need for new anything.

Re:How about

[somersault]

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

[samjam]

but an insider with an outside line can

Re:How about

[Kyusaku Natsume]

Even more disturbing is the fact that the strict controls over several analgesics are creating a new market for drug traffickers, giving even more money to the mafia. The northern Mexican border is filled with pharmacies that cater to the American consumer aside the thriving illegal analgesics market under control of the mayor drug cartels.

Here in Mexico a box of 50 Bayer's Aspirin sells around $USD 3, generics are even cheaper than that.

Re:How about

[ricosalomar]

Don't defibrillators work?
Or does cardiac arrest count as a symptom?

Re:How about

[Dishevel]

How about NO!

Fuck that shit. If the nurse or the doctor is too fucking stupid to get it right they just need to be gone.

We can not as a society keep on enabling the worst of us to make it through life. It is not a good and noble thing that we do. It is the slow destruction of the human race.

Re:How about

[jimicus]

As am I - AIUI there are different severities of colour blindness and being totally unable to distinguish two totally different colours is quite rare.

Being unable to distinguish relatively close shades is rather more common.

Re:How about

[IndustrialComplex]

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..

Not quite. I'm saying that what they are showing there is an exaggeration of what most color-blind people see. The exaggeration isn't helpful since it suggests we see much less color than we actually do and leads to misconceptions.

I have the most common form of colorblindness, and the 'simulation' picture should appear to be identical to the 'control' picture if it were a true representation. Even though colorblindness is more graduated than a simple on-off of wavelengths, it should at least be close. And I'm saying that what I see there isn't even close.

It would be like discussing hay fever alergies and showing a picture of someone in anaphylactic shock.

Re:How about

[Wiarumas]

Even machines make mistakes! My wife is a nurse and was recently laid off due to the machine not recording data (blood pressure). She swears she took it (she has bee flawlessly taking blood pressures for years, multiple times a day), but the machine omitted her recording. Maybe it was her fault, maybe it wasn't. The hospital didn't care to investigate. They said it was easier to prove she didn't take it than to investigate the machine. On top of all this, it was after 3 12-hour night shifts and occurred about 6AM in the morning. Either way, it was completely uncalled for. I guess the floor manager shared the same opinion as the parent: nurses should be like machines and machines don't make mistakes?

Re:How about

[Schadrach]

You mean something like different connectors for each tube type, with the connectors and a band above each end being color and letter coded (with both colo and letter being unique) to make it easier to grab the right one in a hurry, say for example a red connector with a white letter B for IV lines, as they connect to the bloodstream (thus making for an easy mental connection when you need one NOW and it's critical red = blood = starts with B), whilst neither red nor B is in use for any other kind of tube?

Re:How about

[Dishevel]

It is also a process that is not needed. What we need are competent people who take responsibility for doing their job to the best of their ability, What we do not need is more regulations and industries built on the back of "People are to stupid to be expected to do it right."

What are we doing with this mindset. What dose this current climate encourage? What dose it discourage? After you have thought about it is that what you want?

Re:How about

[Red Flayer]

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.

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 maternity ward/wing? How many mothers in recovery, how many newborns in postnatal care, how many actual births happening at that moment? Did they have an unplanned delivery happening at that time?

I've worked in ISO-9000 certified shops where actual compliance was shitty. If you want to get ISO-9000 certified, you just need to demonstrate that you have processes, and that you have processes for monitoring and evaluating compliance with processes. You don't actually NEED to comply.

Re:How about

[somersault]

It's true, you would fall under the "Anomalous trichromacy" rather than "dichromacy" category, but they only put up pics for dichromacy, where one of the colour receptors is completely missing. Still, it's quite possible for partially red-green colour blind people to confuse red and green lights despite what Tom Hudson said.. maybe not if the two lights were next to each other, but if they were shown on their own.

Re:How about

[ArsenneLupin]

Well apart from for the male nurses, who are far more likely to be colour blind..

"No, I didn't suck and swallow. I must have been the mail nurse at my hospital confusing my feeding tube with a different kind of orifice..."

Re:How about

[maxwell demon]

Sure, because there are humans who never make mistakes, especially under stress ...

Re:How about

[LWATCDR]

The color coding or different connectors could just make things worse.
Also we need to look as this as not just one problem.
Take the air to the blood pressure cuff going into the IV.
That one is easy IMHO. A different connector is the solution.
The IV being fed into the O2 line is also easy. Again a different connector is the solution.
Now the spinal anesthetic going into a IV and not the spine is harder problem.
I do not know if different connectors are the solution because both are probably injected into the an IV type line.
For that I think training and more training is the only real solution. Maybe tagging the lines carefully.

I would say that this problem isn't as simple as most commenters on slashdot think it is. I also think what we have is more than one problem and one than more solution.
Thing is this is a really serious problem and great care must be taken. After all if you make it worse more people might suffer and die. This makes things a little more touchy than most programing issues where the worst that can happen is you make more users yell profanities. BTW before anybody bothers to point out programing bugs that can cost people lives please not that I said "than most" and I didn't use the word all. I do know that medical devices, safety systems, and aviation systems all can be life critical systems but that is a small minority of all the programming that happens.

Re:How about

[dave420]

It would make sense to protect people from idiocy, and review the abilities of our healthcare workers, as opposed to letting them kill people and then fire them, which is what you seem to be suggesting. Idiot.

Re:How about

[demonlapin]

I strongly suspect that they meant to talk about an inflatable tourniquet, rather than a BP cuff. The inflatable tourniquets in my hospital do, in fact, have Luer connectors. Of course, we only use them in the OR, and it's pretty easy to distinguish an IV from a cuff...

Re:How about

[Anonymous Coward]

nurses are human beings, not machines.

Now we know how to solve this problem. Replace the nurses with robots!

Re:How about

[ArsenneLupin]

Yellow for evacuation...

Re:How about

[tomhudson]

Spark-plug wires were "never different lengths" to prevent them from being swapped.

Go buy a set. Many times, at least 2 will be the same length.

Keyed connectors aren't a cure-all. Just look at USB connectors - how often do you have to try them 3 times to get them to plug in?

Keyed connectors break; keyed connectors can be bypassed; keyed connectors can be forced; keyed connectors, when you have 50 different keys, become a problem necessitating yet another solution. Simple color coding or even tagging with a stick-on label, are quick, cheap, and customizable to every situation.

Re:How about

[AvitarX]

I think just color coding.

I would think in true emergency settings being able to use the wrong tube could be good, but in other situations, where it is not a matter of seconds for life and death, people could have different colors for different plugs.

But maybe I misjudge how often seconds really matter.

Re:How about

[demonlapin]

gas couplings

Well, PISS and DISS (yes, those are the real acronyms) involve large equipment that isn't considered a disposable. Luer systems are almost all disposable equipment.

It's almost certainly worth the cost, but the cost is real.

Re:How about

[ArsenneLupin]

Insecticide worked for me.

Re:How about

[ArsenneLupin]

It's a symptom of being overweight, not doing enough sports, and having way too much cholesterol in your bloodstream.

Re:How about

[ArsenneLupin]

... but then, this cured only the symptom of having slept with the wrong person...

Re:How about

[socrplayr813]

I work for a medical device manufacturer. Surprisingly, it's not THAT difficult to get a new device approved. It's generally not a picnic dealing with the FDA, but it doesn't necessarily take years either, especially for something simple like a tube with a connector. The problem is that doctors/hospitals/whoever won't want to buy something with an incompatible connector. Unless they're using an entire suite of products for your company, they can't and won't do it. And even then, it takes a lot of loyalty to get them to switch to something like that. Really, if such a change were to happen, it would have to be a new standard that required certain types of connections for different types of devices, which is very unlikely to happen.

There's a lot of inertia in the medical fields. Not to mention, it might make sense cost-wise to have interchangeable connectors and tubes for certain things. I thought the doctors and nurses are supposed to be trained on this stuff. Maybe that's where we should be focusing our efforts in this case.

Re:How about

[IndustrialComplex]

It's true, you would fall under the "Anomalous trichromacy" rather than "dichromacy" category, but they only put up pics for dichromacy, where one of the colour receptors is completely missing. Still, it's quite possible for partially red-green colour blind people to confuse red and green lights despite what Tom Hudson said.. maybe not if the two lights were next to each other, but if they were shown on their own.

I failed a test once because I was actually overcompensating. The test where they show a red/green/white light over another red/green/white light.

What tripped me up? Their 'white' wasn't white. It was that crappy white you get from Sodium Vapor, or a sooty incandescent, so more of a yellow-white.

As a result: Every instance of red-green comparison I got right. But I rarely if ever declared the light to be white since what I saw wasn't WHITE (it was dim yellow/orange-white), so I assumed since I was partially colorblind it must be a faded red and I was just seeing it oddly so I took a guess.

The next time I took the test I got it perfect since I knew that their white wasn't actually going to be white as I understood it, but not before that FIRST test permanently barred me from some career options in the military. (It was too late to go back and switch since I was already locked in)

Re:How about

[glueball]

Cardiac arrest is a symptom of a preexisting disease, usually of arrhythmia, which may be cured by...surgery. Arrhythmia is caused by idiopathic process or by disease such as an MI or by trauma. Using a defibrillator will not cure your trauma or your MI. It may alleviate the symptoms until either surgery or "doing nothing" resolves the problem.

Re:How about

[CaptSlaq]

All these are fine and dandy, but none of them has the elegance and nearly, I repeat, nearly idiot proof-ness of the OPs different connections concept, which I believe has and is used in various other industries to great success. This is not to say that the nurses themselves are idiots for missing the connections when all the tubes are identical but if you can make something strong against idiots its safe to say that educated people should be able to have even greater success.

The idea of incompatible connections removes the inherent flexibility of the current setup, however.

Say that nurse Bob needs X in the next 30 seconds or that patient is going to die. Currently, it's "grab what's available hook it up right, and go". With the proposed solution, it's "Search for the right setup, hook it up and... oh wait, I don't have one of those here."

I won't say "well, it's worked for the past x years, why bother changing it?". I will say that a lot of talk should be done before ANYTHING of that nature happens to sort out the ramifications of the changes that would be made.

Re:How about

[rjstanford]

It's a symptom of being overweight, not doing enough sports, and having way too much cholesterol in your bloodstream.

If that's in the same way that a broken leg is a symptom of having an anvil land on you, then I guess we're all in agreement.

Re:How about

[green1]

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

[oldspewey]

I suspect the answer to your question involves lots of focus group sessions, draft specifications, and requests for comment.

Re:How about

[Dishevel]

Fuck it. I do not care. Go ahead and make the world filled with cold coffee. Put warning labels on everything covering anything. Take away lawn darts. Sharp objects and fill in the Grand Canyon. Flatten the mountains. Set the speed limit at 3Mph. Require that all people constantly wear protective gear at all times. Ban flight, space travel, water sports, sports in general, people saying mean things, religions, atheists and make sure that everyone eats approved foods only and force 12 glasses of water down their throats at the end of every day.

Have a good^H^H^H^H long life.

Re:How about

[ricosalomar]

What about an injury, or anaphylactic shock or something.
No trying to be overly argumentative here. Because I agree with your point, and I want to use it!!
Just trying to try some counter arguments so I can defend.
Thanks.

Re:How about

[harlows_monkeys]

By requiring that every connection/tube be a different color/size, you've now made medical care even more expensive than it already is - hospitals will be forced to stock all manner of spare parts, in sufficient qty for all possible applications - they will no longer be able to stock a huge spool of bulk tubing and cut it down for the application required

All they have to do is have different connectors on the ends of the tubes for different applications. A stock of connectors plus spool of bulk tubing plus a tool to attach the connectors to the tube is all they would need to then cover all their tubing needs. The completely addresses your ridiculous points.

Re:How about

[canadian_right]

All these are fine and dandy, but none of them has the elegance and nearly, I repeat, nearly idiot proof-ness of the OPs different connections concept, which I believe has and is used in various other industries to great success. This is not to say that the nurses themselves are idiots for missing the connections when all the tubes are identical but if you can make something strong against idiots its safe to say that educated people should be able to have even greater success.

The idea of incompatible connections removes the inherent flexibility of the current setup, however.

Say that nurse Bob needs X in the next 30 seconds or that patient is going to die. Currently, it's "grab what's available hook it up right, and go". With the proposed solution, it's "Search for the right setup, hook it up and... oh wait, I don't have one of those here."

I won't say "well, it's worked for the past x years, why bother changing it?". I will say that a lot of talk should be done before ANYTHING of that nature happens to sort out the ramifications of the changes that would be made.

I don't think so. If the patient requires an IV of saline, grabbing that oxy isn't going to help.

Re:How about

[canadian_right]

Actually, having written checklists for complex procedures, eg surgery, is considered a break through idea in medicine that is only recently being adopted by a handful of hospitals. I would say there is room for improvement of medical processes.

Re:How about

[Rob the Bold]

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..

And darkened patient rooms, making color recognition harder for everyone. And probably some other stuff too. But it's a good start.

Re:How about

[Rob the Bold]

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.

Or maybe it does. My dad had that problem. Sure he could tell red green traffic lights apart. Red was on top. Except when traveling to a city where the lights were mounted horizontally. Then he just did what the other cars did. He thought that all squirrels were red, despite that fact that we had both grey and red species where he lived.

Re:How about

[delinear]

There are literally dozens of ways to solve this problem. None of them are exactly brain surgery.

Although ironically some of them might be of benefit when carrying out brain surgery.

Re:How about

[delinear]

Yes, it would be a cheap way to eliminate the vast majority of simple human errors. It might not help the very edge cases with extreme colour blindness, but it doesn't make their situation any worse and it would massively reduce the risks for everyone else (even those with mild colour blindness).

Re:How about

[Rob the Bold]

There are two things that work in medicine. Surgery and antibiotics. Everything else treats symptoms or confirms you need either surgery or antibiotics.

I don't mean this as an insult, but you sound like an orthopedic surgeon. I suppose your statement is true for a sufficiently narrow definition of medicine. Like "physical therapy isn't part of medicine, it's just moving around." And only "treatment counts, not diagnosis". And only curative measures, nothing palliative or compensating, etc.

If you'd said "cefuroxime" instead of "antibiotics", we'd have known for sure.

Re:How about

[glueball]

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. The arrest is merely the symptom.

That said, sometimes you should treat the symptom. I don't want to go into surgery without anesthesia. Anesthesia is not really *necessary* for a positive outcome of the surgery. But it helps alleviate the pain. Which is a symptom of being cut open.

That said, going back to your anaphylaxis argument, treating the symptom of an allergic reaction will not cure the allergic reaction. It will merely make it "survivable" until your own body can compensate.

So if you want a lifetime full of symptom-relief, expect an expensive healthcare system. Most of the people in the ER (I walk out of the hospital through the ER) are there for symptom relief. They think that by taking pain medication they are better. They are not healthier, they just feel better. They think that when they have the flu there is something medicine can do. There isn't anything medicine can do but make you *feel* better and then extract large sums of money. OK, maybe Tamiflu would help but you don't need to go to the ER for that.

If you want a lifetime of healthy living, it's time to start taking responsibility for your health and not treating the symptoms.

My argument isn't perfect but it is a way to consider healthcare.

   

Re:How about

[Anonymous Coward]

Don't be an idiot. How exactly do you think a "dumb" person gets into a position where they can make this kind of mistake? If she was dumb, she never should have been treating patients in the first place - that's a failure of the hospital or her educators to weed her out; if she was inexperienced then she should have been strictly supervised while doing the procedure - again a process failure either on behalf of the hospital or whoever was meant to be supervising her; alternatively, maybe she'd done the procedure many times before and she simply made a mistake, like everyone does. If either of the former are true then the hospital is to blame, if the latter is the case, then don't start using terms like "dumb" until you've either a) gone through life without making a single mistake or b) gone through life resigning from your job every time you make a mistake. Anything less would make you a massive hypochrite.

Re:How about

[tomhudson]

I fail every "find the number" color test in the Wiki article (I don't see any of the numbers, for example), and yet I still can tell the diff. between red, yellow, and green lights, etc., with no problems. Green is still green, red is still red, just that certain combinations of hue and intensity don't stand out the say way as they do for others. Most "color-blind" people are the same way. They'll have no problems distinguishing bands of color.

Re:How about

[sexconker]

Go ahead and force them to use different tubes.

I'll make a fortune selling adapters!

Re:How about

[pandaman9000]

BAM!!! good post!

Re:How about

[sexconker]

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..

I see you take your logic from http://multifamilyinvestor.com/wp-content/uploads/2010/03/calvin-hobbes-world-black-white-color.jpg

Re:How about

[ArsenneLupin]

Score:1, Gardendwarf

Teehee, apparently the fatboy political correctness brigade got hold of some modpoints...

Well, I must admit that myself I am slightly on the chubby side too, but at least I've got a sense of humor...

Re:How about

[delinear]

Most of these screw ups are genuine mistakes, because untrained nurses aren't let loose unsupervised, so they must be happening at the hands of reasonably experienced professionals, and they never would have reached that point if they couldn't carry out these procedures. So how do you improve on a competent person in order to make them flawless, and more importantly how much does that cost, pray tell? You could give everyone more training, you could double everyone up so they can watch each other performing such procedures, you could have more supervisors whose only job is to check all procedures are carried out correctly, you could give nurses shorter hours or longer breaks so they're less likely to be tired and make errors, of course that will mean you'll need still more bodies on the hospital floor at the same time. The cost of doing all that makes putting a coloured stripe or an adaptor on a tube pale into insignificance, and you're still unlikely to solve the underlying issue that people make mistakes.

Seriously, we employ a hell of a lot of people in health, the fact that this type of screw up isn't several orders of magnitude more common than it is is because they're generally doing a very good job under very difficult circumstances. You're right that we shouldn't need laws to enact this kind of thing, because it's common sense and if the medical manufacturers and hospitals cared as much about patient welfare as they do about the bottom line, it would already be happening without regulation. There's an adaptor on my car to stop me using the wrong fuel, there are colour coded ports on my pc so I know where to plug things, but we don't offer the same level of basic thought to a process that could mean the difference between life or death to a patient.

Re:How about

[ricosalomar]

Thanks. Mods, lay some insightfuls on the man.

Re:How about

[glueball]

I don't want to create a scandal, but I do imaging--mostly brain and breast, not surgery. Most of what I look at is confirming whether to do surgery or not--or more properly put, giving an ordering GP or surgeon the information needed to determine a best recommendation for whether to do surgery or not. My research is in making the imaging machine more efficient--either lowering the radiation dose for CT or consulting on designing a better coil for MRI.

Don't get me wrong--PT really helps people and their lives. But putting down the cheeseburger or stopping smoking would have helped more.

Bill

Re:How about

[Dishevel]

Mistakes I get. Hooking up an air line to an IV is not a mistake. It is not paying attention. It dose not matter how many devices you employ. This is something that needs to be fixed at the personnel level. Nowhere else.

Re:How about

[sexconker]

Would you spend (a million dollars per life saved) per year? Well, yeah, probably. (I think the statistic is something like that for mamograms for women over 40 years old.) But what if the number's a lot more?

Would you fear monger to encourage people to cough up (a million dollars per life saved)? Well, yeah, probably. (I think the statistic is something like that for mammograms for women over 40 years old, for routine pap smears, a series of vaccines for a small subset of HPV that may be one cause of some types of cervical caners, etc.)

But what if the number's a lot more?

Even better!

Diseases and conditions are fucking marketable now. Telling people they're depressed and that your drug will fix it, to race for the cure, to send in pink yogurt lids, to get their kids shot up with needless, ineffective vaccines so they can skip rope and be "one less, one less"*, modern medicine (from the pharmaceuticals to the hospitals and doctor's offices) is a sick joke.

Have you seen the fucking commercials that say "2/3rds of people taking antidepressants are still depressed. So take our new antidepressant. We think it works by doing something in the brain. Maybe."? Fucking pathetic.

Modern medicine has become as corrupt as modern academia or politics. The only difference is that modern medicine is still useful.

*I'm not saying vaccines are useless. I'm talking specifically about the HPV vaccine, which won't do shit to prevent cervical cancer, or even HPV, in the long term. It's complete marketing bullshit. They designed the fucking marketing campaign before the fucking vaccine. It has similar benefits in men (with regards to certain colon and rectal cancers), but since those aren't marketable diseases, they can't be bothered to fucking get the drug approved for use in males.
And fewer men with said strains of HPV would contribute to the same "protection" of women with regards to cervical cancer. This is slightly marketable with a guilt campaign "I didn't even know I had it, and now she's dead. Do your part.", but overall, not worth the trials when you can just scare women with ads about kids skipping rope, hoping to not become a statistic (right as you try to get schools to make the vaccine mandatory).

Re:How about

[nbauman]

I've worked in ISO-9000 certified shops where actual compliance was shitty. If you want to get ISO-9000 certified, you just need to demonstrate that you have processes, and that you have processes for monitoring and evaluating compliance with processes. You don't actually NEED to comply.

That's interesting. I just saw an article about process standards in hospitals. One of the requirements is for telling heart attack patients to take aspirin. Another requirement is to "counsel" them on smoking cessation. The electronic medical record has a check box to confirm that you recommended aspirin and counseled smoking cessation. All they have to do is check the box. There's no way to tell whether they actually gave the advice, or whether the patient understood it. The article recommended against unverifiable process standards.

Re:How about

[CaptSlaq]

All these are fine and dandy, but none of them has the elegance and nearly, I repeat, nearly idiot proof-ness of the OPs different connections concept, which I believe has and is used in various other industries to great success. This is not to say that the nurses themselves are idiots for missing the connections when all the tubes are identical but if you can make something strong against idiots its safe to say that educated people should be able to have even greater success.

The idea of incompatible connections removes the inherent flexibility of the current setup, however.

Say that nurse Bob needs X in the next 30 seconds or that patient is going to die. Currently, it's "grab what's available hook it up right, and go". With the proposed solution, it's "Search for the right setup, hook it up and... oh wait, I don't have one of those here."

I won't say "well, it's worked for the past x years, why bother changing it?". I will say that a lot of talk should be done before ANYTHING of that nature happens to sort out the ramifications of the changes that would be made.

I don't think so. If the patient requires an IV of saline, grabbing that oxy isn't going to help.

"I have a bag of saline and no line."

That said, I don't work in that field.

Re:How about

[Anonymous Coward]

You will see your GP who will tell you to go home, put down your cheeseburger, go for a walk, take your own aspirin and call him in the morning.

That sounds like a vast improvement over our current system.

Re:How about

[PopeRatzo]

Here in Mexico a box of 50 Bayer's Aspirin sells around $USD 3

That's about the same price as 50 Bayer aspirin at my local Walgreens.

Re:How about

[SurlyJest]

There are two things that work in medicine. Surgery and antibiotics. Everything else treats symptoms or confirms you need either surgery or antibiotics.

This is nonsense, of course. There are a wide variety of medications for diabetes, hypertension, high cholesterol and a huge number of metabolic/physiological illnesses from Alzheimer's to Yaws (can't think of a "z" disease at the moment).

Re:How about

[southlander]

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.

But of course having them all connect the same way means nurses are faster at connecting things in every-split-second-matters situations. So then the key is to make them all incompatible in a way that also does not hinder speed. Example with a PC -- USB is a snap while connecting a DVI video cable takes a minute. You can never confuse the two, and yet one is much more user friendly.

Re:How about

[compro01]

It has similar benefits in men (with regards to certain colon and rectal cancers), but since those aren't marketable diseases, they can't be bothered to fucking get the drug approved for use in males.

Your information is out of date. Gardasil was approved for use on men almost a year ago.

http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm186991.htm

Re:How about

[ooshna]

The problem with different connectors is if your in an emergency situation and the tube you need isn't there. Sometimes the 30secs to have a nurse run to another room to grab the right tube is life or death. Sure its a rare thing but it happens.

Re:How about

[glueball]

Uhhh, no. Not nonsense. Please tell me which drug fixes Alzheimer's. Sure, there are drugs that alleviate the symptoms. But once a diagnosis of Alzheimer's is made, you've got Alzheimer's. I know of zero people who "used to" have Alzheimer's.

And maybe you're being funny, but Yaws is treated by penicillin, which is an antibiotic.

Diabetes: try not taking medication. You still have diabetes. Same with hypertension.

A "Z" disease is Zollinger-Ellison. It is characterized by tumors on the pancreas or small intestine. Treatment? Either manage the symptoms (thereby not curing it) or surgery to remove the tumors.

Re:How about

[MichaelSmith]

How many nurses did they have in the maternity ward/wing? How many mothers in recovery, how many newborns in postnatal care, how many actual births happening at that moment? Did they have an unplanned delivery happening at that time?

This was a private hospital with a good nurse/patient ratio. In a public hospital she would have had to share a room and would have been better off because there would be more people around to call for help or directly help her. A private room is nice but potentially more dangerous.

Re:How about

[SurlyJest]

Uh, yes, nonsense. Sorry about the yaws, but for everything else listed there are medications that "work" even if there is no cure, which you didn't specify.

Re:How about

[budgenator]

I woke up from surgery, and found I was wearing pneumatic compression leggings and the hoses coming out of them was very typical clear, 2mm vinyl tubing, used in everything from naso-gastric catheters, urinary catheters an even IV tubing; getting that crossed with an IV line would have been catastrophic. Of course I don't think the problem is when there are a few lines, but when the lines turn into a mess of spaghetti; such as a main IV line with another bag of antibiotics and possibly an analgesic hanging on the side. Now add in a gastric tube into the nose, and an oxygen cannula, then there is a urinary catheter. If your at that point there might be a suction line going into the chest to keep the lungs inflated and maybe a few surgical drains; oh don't forget the pulse-oxymeter wires, the EKG wires.

Re:How about

[somersault]

Not really. If someone can't tell the difference between green and red and they choose to represent that by making those colours yellow on the chart, then how will it look to a colour blind person? Yellow is a mix of green and red, but do they actually see both green and red as yellow?

Re:How about

[glueball]

Well, I guess "work" then is a matter of definition and yours is an expensive one. Healthcare is not expensive because of a particular treatment cost, it's expensive because of ongoing and symptom-treatments that are often at odds with lifestyle.

My statement earlier is accurate when you acknowledge that treating symptoms is not a cure and in medicine, we often call a cure something that works as opposed to something that treats symptoms and may not have a disease state change or outcome.

Re:How about

[sexconker]

You make no sense.

If you take a full color wheel and reduce it to the color space a person with a particular form of color blindness can see, then a person with that particular color blindness will see no change.

A normal individual will see the full color version normally and the altered vision in the same manner the color blind individual would see the full version.

The concept you're relying on is that since colors are perceived due to the differences in frequencies and their respective intensities, deciding how to represent a color cannot be determined.

However, these is completely wrong.

If someone cannot see red at all, i.e., their eye does not respond to it, the simple act of setting all red channels to 0 would be exactly what you would need to do to see what they see.

Real color blindness isn't that simple, but it is well-understood and well-cataloged. We can make, and indeed we have made, mappings for many of the forms that color blindness can take. Altering an image to "see what they see" is a simple process of applying the color mapping.

In your scenario of someone not being able to tell the difference between green and red, they would also not be able to tell the difference between any mixture of the two.

Re:How about

[Kyusaku Natsume]

I was under the impression that the prices would be similar to Japanese prices in the US. There I bought a clip of 10 for the equivalent of $USD 8 more or less.

What I can't understand why some analgesics here sell over the counter an in the USA are very restricted. I would guess that NAFTA has some provisions for coordination in the 3 countries, or at least the DEA and the FDA should have interdepartmental talks. It is not like the gangs need aside the business of drug smuggling, people trafficking and protection rackets the business of analgesics too.

PS: please forgive my awful english.

Re:How about

[PopeRatzo]

I would guess that NAFTA has some provisions for coordination in the 3 countries, or at least the DEA and the FDA should have interdepartmental talks.

I think the prices for over-the-counter drugs have more to do with what the pharmaceutical companies want than any trade agreement.

And by the way, your English is a lot better than my Japanese. You don't have to apologize.

Thinking out of the box

[fph il quozientatore]

We should have the tubes manufactured by the same companies that produce battery chargers for mobile phones. Problem solved!

Re:Thinking out of the box

[pesho]

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.

Re:Thinking out of the box

[Walterk]

Ironic comment considering mobile phone companies have decided to standardize on Micro USB thanks to EU pressure.

Re:Thinking out of the box

[characterZer0]

And the National Association of Colorblind Nurses will sue.

Re:Thinking out of the box

[yamfry]

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:Thinking out of the box

[Anonymous Coward]

Everyone here is saying how "obvious" it is that they should have incompatible fittings. While it seems like a great idea, it's really not that simple. If such a plan was implemented, we'd be reading another article in a few years about how many people died because a doctor or nurse couldn't find the right type of tube in time, or how two incompatible tubes that looked similar ended up leaking medicine all over the floor instead of into the patient.

Color coding isn't a bad idea, but there are hundreds of different things that can go into a tube, so it doesn't really solve the underlying problem. Right now a nurse looks at a bunch of identical tubes, and can make a mistake of which is which. With color coded tubes, you'd have a nurse having to stop and think "OK, does morphine go into the fuchsia tube or the mauve one?"

Re:Thinking out of the box

[Anonymous Coward]

Uk researchers have been working on one possible solution to this: http://www.lab4living.org.uk/medical-connectors

Re:Thinking out of the box

[couchslug]

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:Thinking out of the box

[INT_QRK]

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

Re:Thinking out of the box

[corbettw]

Nah, women are rarely colorblind.

<whispers in background>

Wait, there male nurses now? When did that happen?

Re:Thinking out of the box

[kenh]

This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.

Me thinks that Nancy Pratt and Dr. Smith are hoping for their 15 minutes of fame with this Y2K-like "catastrophy" - I'd hate to think a reporter didn't fully investigate the claims of the subject they are reporting on...

Re:Thinking out of the box

[blackraven14250]

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

...or not, if you just put rubber bands around the ends of the tubes near the connectors, or use some of the many, many dyes already used in hospital settings on some of these connectors.

Re:Thinking out of the box

[heathen_01]

Checklists etc are necessary in the military because if you screw up in the military, your ability to kill people is reduced. This is not the case in the mecical world.

Re:Thinking out of the box

[vyrus128]

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.

I hope she was fired and prosecuted, but somehow I suspect otherwise.

Re:Thinking out of the box

[Abstrackt]

Everyone here is saying how "obvious" it is that they should have incompatible fittings. While it seems like a great idea, it's really not that simple. If such a plan was implemented, we'd be reading another article in a few years about how many people died because a doctor or nurse couldn't find the right type of tube in time, or how two incompatible tubes that looked similar ended up leaking medicine all over the floor instead of into the patient.

It's better to have medicine leaking all over the floor than into the patient the wrong way. It's also much better for the doctor or nurse if the patient doesn't die by their hand. That's why everyone is saying incompatible fittings are such an obvious idea. If a doctor or nurse is in an emergency that requires a quick response it greatly decreases the chance they'll accidentally kill someone.

Re:Thinking out of the box

[IndustrialComplex]

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

[martas]

They just don't fit.

You must acquit!

Re:Thinking out of the box

[rtb61]

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

[WCguru42]

We should have the tubes manufactured by the same companies that produce battery chargers for mobile phones. Problem solved!

Tears, tears of laughter and joy.

Re:Thinking out of the box

[idontgno]

Checklists etc are necessary in the military because if you screw up in the military, your ability to kill people is reduced.

Wrong. I'm afraid you're letting your mindless cynicism stand in the way of higher cognitive functions.

If you screw up on military hardware, your ability to kill the enemy is reduced, but your ability to kill friendlies (the operators of the hardware, their wingmen/platoonmates/whatever, other technicians on the apron or in the laager) is enhanced. Just like in the "mecical" world.

Re:Thinking out of the box

[bsdaemonaut]

People actually ask if your color-blind?

Re:Thinking out of the box

[HungryHobo]

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

[bsdaemonaut]

According to TFA at least some of them are, but it sounds like in the example provided the nurse walked away with two misdemeanors rather than the felony involuntary manslaughter charge.

Re:Thinking out of the box

[Anonymous Coward]

How about we require the nurses to go through training and schooling so their jobs aren't a bunch of plug and play wanna-be's like the dell support tecnicians who after exhausting a Scan disk, deleting the tmp files, and rebooting for a no internet problem have you insert the factory restore CD?

I mean seriously, isn't there a test to become a nurse? Isn't there a retest every so often? Does the state regulate these idiots who don't pay attention to what goes where? I really mean seriously, if a truck driver gets confused between the clutch and brake casing the death of someone, we don't run out and blame the TSA or NTSC or DOT for not requiring different peddle types or different colored peddles, we blame the idiot who didn't know their jobs.

Re:Thinking out of the box

[IndustrialComplex]

People actually ask if your color-blind?

Depending on the job, yes. It's not one of the Federally protected disabilities. A lot of jobs require that you get a physical. So the physician will likely perform an ishihara plate test there.

Police, EMTs, Firefighters, anything relating to driving, anything relating to flying, Military. Those are the obvious. They do have some activities which rely on color coded signals.

However a GREAT many of those jobs can be performed by people with the most common form of color blindness. But no hiring manager is going to stick their neck out and take a 'risk'. Colorblindness is VERY misunderstood by the public, and as a result, we will be subjected to a great deal of discrimination because the assumption is that it's the equivalent of walking around blind.

So what will happen is that beyond some of the obvious restrictions (I can mostly understand the restrictions on pilot jobs, though even they are overly cautious, but the FAA is overprotective for a lot of items, and a lot of it is tradition, and not trying to improve what works 'ok')

So you will have someone come up with a rule that if something involves ANY COLOR EVER AT ANY TIME 'normal color vision' will become an employment requirement.

Trust me when I say this, people who are diagnosed with color blindness (even the minor and most common form) know the annoyance and frustration at seeing job postings include those words.

Re:Thinking out of the box

[MMC Monster]

Fine by me. We sure need extra nurses. Just don't complain much when your bill goes up.

Re:Thinking out of the box

[DerekLyons]

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!

In the Navy (in the submarine service), checklists were used for routine things like maintenance - things where you could stop and take your time. For things with time constraints, like fighting a fire or flooding, or other casualty situations, or in combat where time mattered... We were intensely trained and expected to use our memory.
 
Or, in other words, I suspect your comparison is a false one and in many places working in the medical field is almost nothing like working in a hanger and much more like working under combat conditions.

Re:Thinking out of the box

[greenbird]

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.

Wait...who does the "medical" world consider an enemy? That could be important to know next time I'm in a hospital.

Re:Thinking out of the box

[jimicus]

Just to add to what you've said:

Colour blind does not mean the only way I can tell the difference between the red and the green light on a traffic light is because one is above the other. I can clearly see the difference between the two even if they're taken totally out of context.

Colour blind means you probably shouldn't hire me to co-ordinate a room based on 15 different shades of the spectrum which sit around blue and green.

Re:Thinking out of the box

[Anonymous Coward]

Don't tell people you're colorblind. I have a major astigmatism that prevents me from reading things correctly, but I can still get hired with or without glasses because I wouldn't ever tell anyone that I needed them.

Re:Thinking out of the box

[cptdondo]

I would think so.... Military doctors work in inner-city emergency rooms because it's the closest you can come to medicine in a war zone.

I'm an engineer, and was one in the Air Force for years. Heavy construction, working 12 on 12 off under combat conditions is a good way to get killed.

We had checklists for everything. I mean everything we could think of - we even had a checklist for when you didn't have a checklist.

We recognized that, after working a week of 12 hour shifts in the field, then 4-8 hours in the office planning the next day, your ability to made decisions is reduced. So you have a checklist. It kept our people from getting hurt or worse.

Re:Thinking out of the box

[Red Flayer]

Colorblindness is VERY misunderstood by the public, and as a result, we will be subjected to a great deal of discrimination because the assumption is that it's the equivalent of walking around blind.

Obviously, the problem is the term itself... people equate colorblind with blindness because it's got the damn word in it.

I think we should rename the condition, to get rid of that confusion, and introduce new, even better, confusion. "Color vision deficiency", which I've seen used, is obviously too filled with negative connotations... perhaps conic chromatic dysdifferentiation?

Re:Thinking out of the box

[Anonymous Coward]

One in one hundred is. Not nearly as prevalent as the 1 in 10 males, but still significant when trying to design a fool proof system. If it's a health and safety issue, then 1% is way too big a chance.

You'd be surprised how often colorblindness is completely neglected in design. Ten percent of the male population is colorblind to some degree (I'm at the more severe end of the spectrum) yet everything in the world is color coded. In a much less serious category than hospital mistakes, you have no idea (if you have normal eyes) how much the video game world neglects the colorblind. It doesn't prevent me from playing, but it sure makes some things annoying.

Re:Thinking out of the box

[Anonymous Coward]

The Air Force brass are pilots. If the maintenance is screwed up on the aircraft, it's their asses that are on the line. Does wonders for focusing the brass on maintainance performance issues. Flying a warcraft is dangerous enough without the mechanics being exhausted.

Re:Thinking out of the box

[rtb61]

Having 2 nurses allows for better engagement between staff and patient. The checking nurse can engage the patient, to reassure them, lighten their mood and to accurately confirm their current health state, whilst the other nurse provides treatment and also engages with the patient. One of the most important elements of the healing process is reassuring patient, reducing stress levels which substantially improves recovery rates. Two nurses working together will improve their mental health state which will reflect positively in their patient interactions.

Nett affect two nurses working together treat more patients then one on their own, the treatment process if of higher quality and will reduce patient recovery time and, cheaper insurance with a valid provable safety measure. Very tricky to say whether it is more costly or whether it will save money, keeping in mind a million dollar lawsuit employees quite a few nurses for a year. So knee jerk, more costly, carefully thought out likely cheaper.

Re:Thinking out of the box

[yamfry]

I don't know if this nurse was fired or not. I hope so, too. Criminal liability in healthcare is kind of tricky and really needs to be looked at on a case-by-case basis. Generally there are four levels of liability -- at the employer/employee level (fired, reprimanded, re-trained, suspended), at the regulatory body level (lose license, require re-education), criminal level (prosecution in a criminal court), and civil liability (getting sued by an individual).
For employers, the current trend within institutions is to consider all errors to be system errors and not individual errors (my observation, I don't have any data to support this). If someone made a mistake, you perform a root-cause analysis. Even if that comes down to the actions of one person, there can be reasons to push it back as a system error. Was the employee improperly trained? Was the environment too distracting? Was their workload to high? Can you reasonably expect a human to perform hundreds of actions a day without error? If you're coding all day and you make an error, there are layers of QA (hopefully!) to go through before it gets to market. And even after that, you can fix it in a bug report. You don't get all of those things when you're working a double shift in an understaffed nursing unit. That's why we try to make it as hard as possible to mess up.
I don't know that I agree with criminal liability in any but the most egregious cases. And I mean that there is criminal intent. An expectation of perfection is unreasonable. An expectation of perfection with the consequence of criminal prosecution isn't helping anybody at all. Sending a nurse to jail because she was distracted and grabbed the wrong drug doesn't seem just to me.
Nobody in healthcare likes making mistakes. I can honestly say I've made mistakes and luckily none of them have caused harm. It's changed the way I practice for sure, but I know that I am flawed and will make errors again. I work with other flawed people and I learn from them. Whenever I hear of a medical error harming a patient (and I think this can be generalized to all but the most sociopathic of healtcare workers), I get the sickest feeling in my stomach. In the same environment, with the same mindset, could I have done the same thing? Taping two tubes together because they don't fit? Probably not.

Re:Thinking out of the box

[jbeaupre]

Invent something that is idiot proof and someone will just invent a better idiot. I say this partly in jest since most people really are trying to do the right thing. As your anecdote shows though, it's tough to engineer in safety against people actively trying to screw things up (even if they think they are "fixing" it). But I've had to try.

I used to work for a large company designing medical products. We would bring in the top surgeons to test our products, validating their safety. My complaint was we needed to find the worst doctors and have them try it. But I could never figure out how to diplomatically recruit from the bottom 5%. So I was stuck testing with non-idiots.

Re:Thinking out of the box

[Krishnoid]

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.

Both of which are discussed in this story in the context of checklists, a pretty good read. Props also to the very apropos Idiocracy reference; I won't give away the joke as its one of the best ones in the movie:

from the no-wait-this-one-goes-in-your-mouth dept.

Re:Thinking out of the box

[zstlaw]

Here in Boston I know a hospital was fined for having a checklist because it was not a medically approved procedure. It had improved outcomes substantially yet was deemed an unlicensed procedure because it hadn't undergone years of clinical tests...

It was a freaking checklist!!! And it had reduced surgical complications about 15%! Things like 1. All staff have washed hands and tools before first incision. ...snip... 5. All tools are accounted for before patient is closed. Luckily the checklist is now back and becoming popular at many hospitals.

Sometimes I wonder how doctors and nurses keep from going insane when they are not allowed to even use a checklist! (Note in this case management supported the checklist it was an outside audit that caused all the problems.

BUT then I go to a well run institution and see that the real differentiator between good and great institutions seems to be quality of the support staff AND whether procedures are standardized and regularly updated.

If the hospital is well run it runs like a finely oiled machine because anyone can swap in to an ongoing procedure and know exactly what has and hasn't been done since the process is standardized. There is no double drugging, no lost tools, etc. But I also see that in far too many institutions the providers have immense power to do as they want and as a result each group or specialty defines their own processes and honestly few doctors are great at logistics/organization. It just isn't what they were trained for.

I have seen group practices that literally leave a patient waiting until a doctor decides they WANT to see that patient's case. Until then the patient sits waiting, meanwhile another patient may be seen several times because the case is more interesting. This is the case of an awful physician run patient scheduling process.

As far as I can tell most of the nations medical institutions would greatly benefit from having to follow a special procedure dictated by a central authority. The best institutions already do a good job defining best processes but the hospital nearest you probably can't tell if you already were tested for a disease and whether the test results were available without sending runners to multiple other departments.

I have seen people with life threatening conditions be sent home and told "call if the problem gets worse". The condition in one case was a failing heart with 2 chambers no longer working. (Another hospital took him in and operated the same day since he was literally about to die). Another time it was a stage 4 cancer patient whom they failed to diagnose even though the patient had come in requesting the specific test that would identify the cancer. He had to go back several times demanding the procedure then finally paid out of pocket somewhere else to prove he had stage 4 cancer. The first hospital just decided that it was random lumps in his neck and that he was wasting doctors time second guessing them.

Checklists and best processes can save lives, but I doubt most hospital could make the proper checklist or even identify why outcomes are not improving. Hospitals need 4 things to be successful. 1) doctors who are up to date on latest practices 2) efficient management 3) well trained support staff 4) good billing processes. Most places have maybe two of that list. Management and billing could be better centralized. A nationalized medical system with public payer instead of private insurance would have taken care of both management and billing. Sadly what was passed did not go far enough to fix those aspects. (It would still not be easy, but I work in the industry and what I see repeatedly is things that are standardized though central mandate are the only things most facilities do properly.)

Re:Thinking out of the box

[Cogline]

New laws aren't really necessary, as the existing ones can be used to force additional improvements in this area. The manufacturers of the tubes are already held to FDA 820 for design and development, 21 CFR 820, of which section 820.30 (g) calls out risk analysis during validation. All the FDA has to do is indicate that the risk analysis includes foreseeable misuse which includes incorrect tubing connections, and all manufacturers will have to be able to demonstrate that their device is incompatible with a (justifiable) subset of existing similar tubes.

The FDA is already aware of the adverse events (21 CFR 820.198), and may even see trends. Some of these cases are the result of overstressed individuals, for which better staffing is the best answer. But for some of these cases I'll borrow from Forrest Gump, "How do you fix stupid?"

Moreover, would you want the government backing a specific industry standard for tubing? I can foresee many ways in which that system could be abused. The FDA is hoping someone else steps up and makes it easy for the different manufacturers to cooperate on this.

Re:Thinking out of the box

[neapolitan]

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

[pspahn]

No need to get PC with this. Just call it something adequately descriptive, but use words that your typical HR genius won't know the definition for.

Maybe something like "HSL Amaurosis".

Re:Thinking out of the box

[vyrus128]

Yeah, I guess I should be clear. I absolutely believe that most failures in healthcare are systems issues. I would never want a nurse to be prosecuted for making a mistake. I just read this story as "a nurse deliberately bypassed a safety feature, resulting in the death of a patient." You're absolutely right that even then, it could be a training issue, or a workload issue, or a combination of factors. I shouldn't be too quick to judge.

Re:Thinking out of the box

[Anonymous Coward]

Can't you just not tell them about it?

Re:Thinking out of the box

[rickb928]

"but get caught without a job guide and it's yo' ass!"

Absolutely! The guys in OMS had guides to reassemble F-4 main brakes. And it still got done wrong from time to time, with predictable results. Here is one case where the Navy had it all over us in the USAF - brakes never had to do much on a carrier except park and taxi, which even the badly assembled ones would do. Arrestor cables are not common at AF bases.

But the industry really should take charge and give the FDA something to approve.

Re:Thinking out of the box

[couchslug]

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

[Anonymous Coward]

Wait...who does the "medical" world consider an enemy? That could be important to know next time I'm in a hospital.

It's an analogy, but if you must have a real-world example, consider a broken autoclave... poorly-disinfected tools can kill a lot of patients. (Or the "tainted blood" scandal back in the 80s/90s, in which HepC-infected blood made it into the blood banks.)

Re:Thinking out of the box

[couchslug]

Outside trauma and emergency medicine, perhaps, but the "crisis managment" mentality is clearly inappropriate to most care, which involves _scheduled_ appointments, examinations, etc.

If we are doing a comparison, a combat turn on an F16 with intake inspection, servicing inspection, weapons load, etc can be done in under 20 minutes (hot refuel done on the taxiway). The Weapons folks have the checklist open and mark off the steps using grease pencil. The process is hectic, but a key part of control is the checklist.

I put down the resistance to checklists outside of dire emergencies ("dire" being outside even of most ER visits) to elitism.
If a pilot can abide by them (including some emergencies) then other skilled people have limited excuse.

http://www.allgov.com/Where_is_the_Money_Going/ViewNews/Medical_Errors_Cost_Americans_19_5_Billion_Dollars_a_Year_100823

Re:Thinking out of the box

[Ant P.]

Any doctor who knows their stuff would probably consider Evil Pharma's advertising department the enemy.

Re:Thinking out of the box

[Anonymous Coward]

Yet, 2 pilots can end up causing a crash because both forgot to deploy the flaps.

2 people is not fool-proof, but it helps.

Re:Thinking out of the box

[Malenx]

The vast majority of time spent in the medical field is routine normal work. Yes there are emergency situations that require you to run off memory, the same exists in every branch of the Military, including the Airforce.

But everyday tasks performed in the Airforce have checklists associated with them. If it can be defined, it has a procedure. There is a real strong sense of excellence and safety in what the Airforce does every day.

Worked on a plane while I was in the Airforce. If a single allen wrench was missing from your toolkit, you had an hour to find it. If it was still missing, the plane you did maintenance on was grounded until it was found

Re:Thinking out of the box

[RobinEggs]

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.

Or you can just use striping on the outside of the tube, rather than making the tube out of solid, colored plastic. The striping could include a text-label or pattern for the color-blind. In any case many dyes are FDA-approved as food safe; look at the nineteen bajillion varieties of plastic drinking glasses and children's tableware. Making sturdy, completely incompatible connectors isn't too hard, either; they're all over in the industrial applications of gases and dangerous liquids, so it's plausible to adapt them cheaply and directly to the medical uses.

Re:Thinking out of the box

[Anonymous Coward]

Just one: Electrical

Re:Thinking out of the box

[suutar]

An even better reason to have incompatible fittings (as well as color coding. Coding makes matchup faster, fittings make it error-resistant).

Re:Thinking out of the box

[Anonymous Coward]

Wait...who does the "medical" world consider an enemy? That could be important to know next time I'm in a hospital.

Lawyers.

Re:Thinking out of the box

[budgenator]

Dude just take out your credit card, and order the plates and memorize them

Re:Thinking out of the box

[Anonymous Coward]

In other words it's all good until they run out of resources and have to reused tubes and containers, buy $2 adapters for tubes rather than a $10 new tube, etc.

Re:Thinking out of the box

[Anonymous Coward]

Posting anon since I modded earlier in this thread...

My dad was in the hospital for an extended period of time... the first hospital that he went to refused to do any tests on him, sending him home with antibiotics for what ultimately was a brain aneurysm, even though he had a prior brain aneurysm, had been under a lot of stress recently and had a head injury a couple days earlier. Prior to surgery at the second hospital, we had his lawyer come up to draw up a Power of Attorney and whatnot, just in case anything happened, so I could handle everything outside of the hospital as well as inside (since I was his medical proxy as well). I mentioned the possibility of suing the first hospital and his lawyer just about bitchslapped me, told me to shut up and asked me to follow him someplace private.

Now, you'd think hearing "lawsuit" would make things better for a patient... but, in reality, it makes it worse. Instead of ensuring the patient gets the best care, it means they'll get the exact, by the book care. That way, if you sue, they can say "see, I followed our standardized procedures exactly." In my dad's case, that meant he never would have had the risky new surgery that saved his life (though it did cause a stroke that left him paralyzed on his left side). Ultimately, I'll take a disabled dad over a dead one, so the stroke was a risk that both him and I were willing to take when we were informed of his options. But, we never would have had that choice if the doctors knew we were talking about suing the first hospital...

Speaking of "just following procedures," in the end, I couldn't get a lawyer that wanted to go after the first hospital... apparently, it's perfectly acceptable for an emergency room to tell you that you have food poisoning after refusing to run any tests on you despite your presenting symptoms, medical history and recent events. You'd think that would be a clear cut case of malpractice, but, hey, he followed the hospital's rules.

Re:Thinking out of the box

[Anonymous Coward]

Biology is not as checklistable as mechanics. Even high-end surgical consultants have frequent meetings (weekly or more) with other high-end surgical consultants about day-to-day cases. Not something you get when you're a veteran with a spanner.

Re:Thinking out of the box

[sznupi]

On the bright side (judging by few sites displaying several variants of one photograph, each portraying one type of color blindness) - there's a high chance that the way you see the world is interesting enough to make Hollywood films be color graded similarly.

Re:Thinking out of the box

[sznupi]

We blame the idiot? How many "runaway acceleration" media circuses were about blaming the idiot?

Re:Thinking out of the box

[bill_mcgonigle]

"Color vision deficiency"

Everybody who's not a tetrachromat is "color-vision deficient".

I have a color vision I haven't found a name for yet - most colors are discernible with enough of it, but many aren't in small samples. I can also see pretty well in almost-total darkness (my job in the car at night is to point out all the animals standing by the side of the road). I suspect I have 'too many' rods and 'not enough' cones, but generally there may be more variation in color vision that a few small categories describe. So lots of the population may have 'deficiencies', depending on how that's measured/defined. The dot-card tests call out a few specifics, but what else isn't measured?

Re:Thinking out of the box

[cynyr]

which sort of color blindness do you have? probably red/green Deuteranomaly.

Hrmm, i just though of every machine i've worked on has had red buttons for stop and green buttons for go, and if they looked the same that might be a problem.

Of course most people assume that colorblindess == Monochromacy even though that is the rarest type of color blindness.

Also, how do you define colorblindness for disability purposes? full Monochromacy? see it would require large amounts of education to people that do not understand science at all, and would there for have no idea how to spot test for any of the colorblindness types, also some jobs may or may not actually require full color sight by some regulation (OSHA perhaps).

labels?

[Anonymous Coward]

No?

 

Well...

[Anonymous Coward]

On the other side of the coin...

I could see such a system leading to patient deaths because of their complicated color system. 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.

I guess the real question is: What do nurses think?

“This is a deadly design failure in health care,” said Debora Simmons, a registered nurse at the University of Texas Health Science Center who studies medical errors. “Everybody has put out alerts about this, but nothing has happened from a regulatory standpoint.”

At least one nurse from TFA agrees that there is a problem to be solved. Who would know better than someone in the trenches?

Re:Well...

[DarkKnightRadick]

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:Well...

[somersault]

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:Well...

[tibit]

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...

[MichaelSmith]

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. 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:Well...

[IndustrialComplex]

n 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.

As a color blind individual, and thus familiar with a lot of attempts to make things 'simple', may I suggest something like this:

||| connects to |||
| connects to |
-- connects to --
+ connects to +

A simple labeling process can be built into making the termination of the tubes. You don't want to obscure the lines too much, and simple character based ends could eliminate color confusion and matching up a pattern down the line (which can get tricky if you only see the end of the tube and the rest is obscured by bedding, tape, etc)

Re:Well...

[TFAFalcon]

I could see such a system leading to patient deaths because of their complicated color system. 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.

Giving patient something NOW won't help you if you put it in the wrong part of the patient, and that's exactly what this article is about. Even if a drug and the time to administer is crucial, injecting it into the patients breathing tube instead of IV will likely not help the patient survive.

Re:Well...

[demonlapin]

You're going to put your thumb on the end of a tube that has a patient's blood at the other end? Not exactly good sterile technique.

The best solution is probably to continue to use the existing Luer system for intravenous sets and alter the sets used for epidurals and feeding. Of course, you'll have to come up with a solution for arterial lines (can't use those to inject drugs, but they are currently manufactured just like IV lines and rely on proper labeling) and air systems.

Re:Well...

[somersault]

You're going to put your thumb on the end of a tube that has a patient's blood at the other end? Not exactly good sterile technique.

I have a few friends who are doctors, one was telling me recently of how he's the only doctor in his ward on nightshifts, and at some point he may have to re-open a surgical wound to look at a heart if there is a serious problem with one of the patients. He mentioned that he may actually just have to stop a leak with his finger until proper help arrives, which I found a little strange, but practical.

Re:Well...

[demonlapin]

If you're reopening sternotomies at the bedside, sterility is the least of your problems.

Re:Well...

[somersault]

I think it's in the theatre with nurses by that point, but still he isn't really qualified to do any actual heart surgery.

beacause

[Spaham]

"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 !

Re:beacause

[Anonymous Coward]

You're forgetting that in the US, the hospitals in many cases, ARE the industry. And tubes are expensive...

Re:beacause

[BubbaDave]

The for-profit hospital industry, not the medical components industry.

Dave

Re:beacause

[Overzeetop]

But the FDA does not regulate or promote the for-profit (or non-profit) hospital industry. They do regulate the medical devices industry.

Color codes? Different connections?

[captainpanic]

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.

Re:Color codes? Different connections?

[Anonymous Coward]

Colour blind?

Anyway, this can't be fixed. If you use incompatible sizes or connections, you'll just hear about how nurses try to break the tubes to make them compatibles instead. When people are stressed for time, they won't be doing much thinking.

It's about education and experience.

Re:Color codes? Different connections?

[mcvos]

Man, hyperbole is so hard to spot these days!

Re:Color codes? Different connections?

[captainpanic]

Colour blind?

Anyway, this can't be fixed. If you use incompatible sizes or connections, you'll just hear about how nurses try to break the tubes to make them compatibles instead. When people are stressed for time, they won't be doing much thinking.

It's about education and experience.

It takes less time to get a new (correct) tube than to fix two non-compatible ends together.

And anyway, it can be fixed. No nurse, no matter how stressed for time, will knowingly attach an oxygen line to a tube that she knows goes directly into the blood. So, the only thing the color codes or connections have to do is to be a reminder of what's what.

Re:Color codes? Different connections?

[TFAFalcon]

At least being able to prove that a nurse made an extra effort to make a mistake will give you grounds to fire him/her.

Injecting something into the wrong tube in a bundle of 10 identical tubes can be forgiven. Taking 5 minutes to force incompatible tubes together can't.

Re:Color codes? Different connections?

[WCguru42]

How about using color codes?

In chemical industry, and in labs, color codes have been used for the last 15 millennia or something.

I think that falls squarely on the "or something" time frame.

Re:Color codes? Different connections?

[Anonymous Coward]

It appears that your ability to process hyperbole has been damaged. Hypoxia due to incorrect intubation?

Re:Color codes? Different connections?

[Anonymous Coward]

Read the memo.

Have you ever been in a stressful situation at all? People will do whatever, they think, they need to do.

Re:Color codes? Different connections?

[Anonymous Coward]

Lies I tell you! Just look at old movies, there were no colors back then!

Re:Color codes? Different connections?

[Anonymous Coward]

I agree. We even color code the connections on the back of a computer, as well as have some that are different connectors. Why could they not figure this out decades ago?

Ummm Personal responsibility?

[realsilly]

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.

Re:Ummm Personal responsibility?

[Freddybear]

It's much easier to blame "industry" and call for more costly government regulation than it is to check both ends of a piece of plastic tubing?

Re:Ummm Personal responsibility?

[paiute]

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?

[txoof]

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:Ummm Personal responsibility?

[Issarlk]

So we need to make fail-proof nurses instead of making fail-proof tubes.
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:Ummm Personal responsibility?

[Rakshasa Taisab]

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 annoying patient that keeps complaining and demanding attention, etc, or any number of other things that can lead to fleeting moments of inattention.

The best solution here is to make it impossible to connect tubes to the wrong device. Simple, effective and takes the human out of the equation.

Re:Ummm Personal responsibility?

[American AC in Paris]

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.

...or is this some newfangled variety of personal responsibility that completely eliminates human error?

Re:Ummm Personal responsibility?

[$RANDOMLUSER]

That's a great idea. Rather than making a few simple changes to the interface, we'll let the Invisible Hand solve the problem. Hospitals that hire nurses who make the occasional simple, human mistake will eventually go out of business. That's brilliant. I'm so glad we have Republicans around to show us the Right Way (tm) to do things.

Re:Ummm Personal responsibility?

[Anonymous Coward]

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:Ummm Personal responsibility?

[TapeCutter]

"Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job..."

Your the one human on this planet who has never made a stupid mistake, right?

Re:Ummm Personal responsibility?

[corbettw]

A government bureaucracy won't allow manufacturers or operators to make consistent changes to a product, yet it's the free market that has failed. Mr. Orwell would be so [proud|aghast] (take your pick).

Re:Ummm Personal responsibility?

[Anonymous Coward]

You clearly haven't met too many idiots.

Most of the ones I know would go "Hey bubba, this don't fit. Hand me my duct-tape."

and now instead of a tank attached to the wrong equipment you have a tank unsafely attached to the wrong equipment. Not as much of an improvment as you may think.

Re:Ummm Personal responsibility?

[radtea]

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:Ummm Personal responsibility?

[mcgrew]

Your comment really fits your user name. You've never made a mistake? You never heard of Murphey's Law? Making these tubes all the same with the same fittings is insanely irresponsible. What about some personal responsibility from the manufacturers?

Re:Ummm Personal responsibility?

[goodmanj]

Asking whether a problem is caused by design error or human error is a false distinction. If the design *permits* human error, it's not a good design.

Gas stations don't rely on "personal responsibility" to keep you from filling your car with diesel: they make the diesel filler tube incompatible with a gasoline fuel tank so it's *impossible* to screw up.

Another car example: the Toyota "unintended acceleration" thing. Was it driver error, hitting the wrong pedal? Or is there a design flaw in the car? Even if every case was caused by people hitting the wrong pedal, there's still a design flaw, shared by all cars: the frickin' gas pedal is right next to the frickin' brake pedal, making human error inevitable.

Now, for complex tasks, like flying a plane, it may be impossible to make design good enough to eliminate human error. But for plugging a tube into another tube, there's no excuse for error-permitting design.

Re:Ummm Personal responsibility?

[g4b]

but stressed people trying to find the stuff to bring you into a stable state might not have the time to search for the right cable.

this is also the answer to this whole debate, which is kinda something you learn in your second year at medical university.

this, and education.

normally, direct vene tubes are also colorcoded and you can find big signs put on it afterwards, because some doctors try to prevent this. also it is policy in some of the hospitals i have been.

but after trying out incompatible systems with each other for some time, most hospitals decide to go with the "easy basic standards" again, because the rate of failures is even higher if you have to learn 20 types of catheters to use.

not every medical guy is geeky. other stuff is way more important in some situations.
bottomline, causing death by mistake will not be avoidable, ever. you can avoid mistakes made by medical personell by not using any medical facility.

Re:Ummm Personal responsibility?

[pehrs]

So, in an emergency situation you prefer the nurse/doctor to spend their time tracing and marking which tube goes where, using their private system, instead of concentrating on, say, delivering the right amount of the right drug?

How many good, experienced, sysadmins have not once or twice in their careers executed a dangerous command on the wrong computer?

Re:Ummm Personal responsibility?

[captainpanic]

You clearly haven't met too many idiots.

Most of the ones I know would go "Hey bubba, this don't fit. Hand me my duct-tape."

and now instead of a tank attached to the wrong equipment you have a tank unsafely attached to the wrong equipment. Not as much of an improvment as you may think.

Unfortunately, the main difference between chemistry and medicine is that people who act stupid in chemical labs often get a Darwin Award (they kill themselves). In a hospital, they kill someone else.

And that's why I think the situation in chemical labs is good enough, while hospitals can use some improvement.

Re:Ummm Personal responsibility?

[Anonymous Coward]

Bags be the Invisible Hand when Cheney's heart next needs a 10,000,000 beat check up

Re:Ummm Personal responsibility?

[Anonymous Coward]

...or is this some newfangled variety of personal responsibility that completely eliminates human error?

So maybe not personal responsibility as much as some humility? I've never met a nurse that didn't think they were smarter than the doctors they worked under (despite many demonstrable tests available to disprove such a theory). Nurses are hard workers, but so many of them have their heads up their own asses that the potential for mistaking one tube for another is obvious.

Re:Ummm Personal responsibility?

[kevinNCSU]

Did you even read the post you're responding to or did you just go into an anti-free market anti-republican frothing tizzy at the very mention of the words "personal responsibility"?

And, when did double checking to make sure things are correct when a life is on the line and "personal responsibility" become intrinsic values that clearly identify the Republican party anyways? I must have missed that memo. There's nothing political or market related in the entire post you're responding to, all he said is color tubing would be a good idea but it's ultimately the nurses responsibility and it's very easy to double check a tube.

Re:Ummm Personal responsibility?

[gnasher719]

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?

[interkin3tic]

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.

Exactly what I've been saying about stop lights, seat belts, speed limits, crosswalks, and turn signals for years! Just be responsible and everything will work out alright, no accidents!

Re:Ummm Personal responsibility?

[interkin3tic]

"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...

Well, maybe if the nurse hadn't stopped to make and laugh at his or her own pun...

Re:Ummm Personal responsibility?

[agent_blue]

I agree with this. You don't get to be a nurse without some kind of training, and presumably the training includes something about tubes and how connecting the wrong tubes could be deadly. If the nurse knows that they could kill someone by connecting the wrong tubes, then it would be negligent manslaughter for them not to double check.

We should not replace due-diligence with color codes and connector gimmicks.

Re:Ummm Personal responsibility?

[Anonymous Coward]

Clearly you didn't read the article.

That "invisible hand" is *trying* to solve this problem; remember that part about "incompatible tubing", which manufacturers are busy creating ad hoc? Yeah. That's the embryonic stage of a standard. (Don't believe me? Think back to network protocols. How many LANs, precisely, are *not* Ethernet today?) Some of them are baying for the FDA to step in and mandate a solution, so that their "standard" (which they already have tooling to produce, i.e. a competitive advantage, and almost certainly patents for) becomes fiat, thereby making them Big Bucks. That isn't going to happen, unless the FDA decides it has a favorite and wants it to obtain Epic Profit. The usual pattern is that the industry flails for awhile, then settles on a global standard (e.g. NPT, Cat 5, standard electrical color-coding, &c.) that is adhered to by every major player in the field, causing all the minor players to fall in line or die. This is what happened with gas and fluid connections in industrial processes, for example; insurers decided they were tired of paying for some idiot's design being responsible for turning a factory into a Roman candle, so the codes reflected the requirement to make certain things (e.g. flammable gases and oxidizers) fundamentally unconnectable except in well-controlled circumstances.

Now, I am a libertarian, but in *this particular case*, government might be able to accidentally force a solution faster than a congeries of independent producers could; by promoting a particular connection standard, the FDA would be in a position to preclude patent protection on the design, and a spec for a standard set of carefully incompatible connectors would make this problem vanish overnight. Factoring human-powered accidents out of the equation - e.g. by making feeding solutions non-connectible to IV lines - is essentially risk-free (since that never needs to happen anyway), and makes everybody happy.

Re:Ummm Personal responsibility?

[wisnoskij]

But for good or ill most health care is done using Humans.
If it is not this then it is something else that they will manage to screw up.

If you make the workplace too simplified and foolproof, then they will just end up paying less attention overall and people will still die, just using other methods.

Re:Ummm Personal responsibility?

[$RANDOMLUSER]

It's not my reading comprehension that's in question. If you can't identify a post that starts off with:

Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job...blah blah blah blah

as a quintessentially Republican screed, then you're either: a) not paying a lick of attention, b) dishonest, or c) a Republican.
Oh. Wait.

Re:Ummm Personal responsibility?

[Anonymous Coward]

Yep. Systems, systems, systems.

Blaming the person is what the 19th century railway industry did. 50 people dead in a crash? Say the driver may have been drunk, and if he's alive, fire him for incompetence.

But it didn't work, they kept firing drivers but the people kept dying, because the "incompetent" drivers were only human, and so were their replacements.

So in the mid 20th century they would respond to each problem with an engineering solution. 50 people dead in a head-on collision? Fail-safe interlocks to prevent clearing opposing signals.

That worked better, but it wasn't enough. Too many people still died.

In the late 20th century through to today they've realised it's the whole system you have to examine. Whenever something _nearly_ goes wrong, you try to find at least two ways things to be improved that will prevent it happening again, because next time you might not be lucky.

For example, a while back one of the very high voltage cables needed for the Eurostar service melted in the terminus, causing a live cable to hit the platform, and it was only luck that prevented it killing a passenger. Not one, or two but half a dozen changes were recommended to systems, including changes to working practices (an electrical technician assumed the fault was transient and re-enabled the power without asking), to installation (the cable was installed wrongly), and the technical requirements for the power system (greater margin between the maximum intended load and the cable design load). Most of those changes would have been enough on their own to eliminate or significantly reduce this risk. But why stop at one?

Re:Ummm Personal responsibility?

[firewrought]

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?

Good design anticipates human performance errors and safeguards against them. You ALWAYS want to include appropriate labeling, lockouts, and other such features when designing safety-critical equipment. This is not a surrender of personal responsibility on behalf of the end-user: it's an embracing of professional and moral responsibility by the designers of such equipment and the administrators of our institutions.

Re:Ummm Personal responsibility?

[jimicus]

I've met girls with that kind of attitude to something potentially risky - "Just be careful".

Most of those girls are now mothers.

Re:Ummm Personal responsibility?

[Anonymous Coward]

Ever worked a double shift dude??? If there is a way to screw up a life and death situation there should be safe guards against it. Making connections specific should not be that hard, a few extra cents, these are small pieces of plastic....

Re:Ummm Personal responsibility?

[kevinNCSU]

Well I guess we'll have to mark me down for option A as I missed the memo that no matter the question at hand, how big or small, if someone suggests anyone should be personally responsible for doing any part of their job correctly than they're a republican shill.

Re:Ummm Personal responsibility?

[sorak]

Agreed. Personal responsibility is just a way for larger entities (the businesses that make the tubes, the FDA, the hospitals, etc) to dismiss it as someone else's problem. Who cares if the problem continues, as long as we now know who to blame!

Re:Ummm Personal responsibility?

[thisissilly]

If they have a 0.001% failure rate they will still err every decade or so.
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?

[$RANDOMLUSER]

Reading comprehension fail #2. You're assuming that I meant that A, B and C were disjoint. Actually they're almost completely overlapping.

Re:Ummm Personal responsibility?

[Dragoness Eclectic]

There's a name for it: Defensive Driving. Assume the other drivers on the road are all idiots and be ready for them to do stupid, unlikely things. It works.

It encourages you to do things like maintain situational awareness ("The cars a mile up the highway are all backed up in a jam. Maybe I should slow down"), maintain proper separation ("The guy ahead of me may suddenly have to brake for a deer bounding across the road" -- has happened to me), keep a safety margin on your speed ("Wheee, hydroplaning is fun!"), don't coast in someone's blind spot ("That semi wants to change lanes NOW, and he doesn't know I'm here. Oops"), DON'T assume the guy looking your way before pulling out on the road actually sees you (I smashed a car up making that mistake, once), etc.

Re:Ummm Personal responsibility?

[maxwell demon]

If the nurse knows that they could kill someone by connecting the wrong tubes, then it would be negligent manslaughter for them not to double check.

And you believe that double-check reduces the number of errors to zero?
Not to mention that in certain situations, the risk of the patient dying due to the extra time of the double check may actually be higher than the risk of the patient dying because of the risk to have erred the first time.

Re:Ummm Personal responsibility?

[Anonymous Coward]

This guy's nurse connected the "asshole" tube to where the "mouth" tube should have gone.

Re:Ummm Personal responsibility?

[BJ_Covert_Action]

This system is virtually idiot proof.

I have a few friends and a Youtube-ready video camera that would like to challenge that assertion....

Re:Ummm Personal responsibility?

[kevinNCSU]

Emphasis mine

you're either: a) not paying a lick of attention, b) dishonest, or c) a Republican.

Reading comprehension fail #2. You're assuming that I meant that A, B and C were disjoint.

You are correct sir, I did in fact assume you had enough reading/writing comprehension to know that the terms "either...or" unequivocally implies disjoint non-overlapping options. This might have been an overestimate of you on my behalf but since believing in my own personal responsibility would apparently make me a republican I'll choose to blame you instead ;)

Re:Ummm Personal responsibility?

[rickb928]

"Another principle that has served me very well while driving a car: People make mistakes"

Yes. You may have NO IDEA how often some other drivers response and thinking saved you from an unfortunate accident, or death. And rest assured that most of the time they will NOT shake their fist at you and make mouth signs. Being aware enough to avoid the problem also tends to leave you not indulging in displays of aggression, lest you then cause the accident you just avoided.

Of course, I bet many of these mistakes were part of a circumstance where regular procedures and routine events were somehow interrupted or changed. Same way with cars. It's not the routine, it's exception, that is at the root of many a problem. But nurses do not always get to dictate their routines.

Re:Ummm Personal responsibility?

[Anonymous Coward]

I'm sure when you wrote your post there was a hint of aggravation in your demeanor because it would seem obvious that you are employed in a field represented in this news brief. Taking that into consideration I would hope that most of the people who read your reply will overlook your obvious slander towards anyone younger than 30. This is the twenty-first century after all, one in which young men and women right out of high-school are accepting jobs requiring the utmost responsibility. As hard as it may be for you or even myself to accept, the reality is that there are nurses out there who are in fact incompetent with what they do (as with any field). The majority of workers in the medical field are true heroes no doubt but let me entertain your sense of consideration with a true story. Some years ago my grandfather was in need of a quadruple bypass and one of the procedures required was to inject a very very small amount of minute air bubbles into his bloodstream for analysis of blood flow. The nurse at the time was indeed below what I would consider competent and promptly began to insert a large syringe with a deadly amount of air into his iv tube. Well the outcome was agreeable because of the vocalization of the others in the room at the time, in other instances it's not. The nurse though admitted she had never performed that technique before and yet still attempted to go through with it without asking for assistance. That is a case where color coding and proprietary attachments would have done no good and it was all a matter of "Personal Responsibility". What I am leading up to is strictly my opinion and nothing else besides perhaps logical thinking. I agree with many of the other posts when they say that the shift scheduling of many nurses and doctors are absurd. Also to allow someone who is obviously unsure of what they are doing in their job to continue performing it is just as ridiculous. There is no excuse with the availability of training facilities and knowledge out there to have anyone but the best in all facets of the medical world. The only reason not to would be time and haste issues but in my example there was plenty of time to bring in someone capable and experienced to monitor the nurse who was lacking and allow that person an environment to grow in. Long rant short: Tube identification parameters must be reformed, training must be improved for those who are expected to maintain the lives and health of others and the atmosphere of nurses not feeling able to reach out to their peers for help without feeling criticized must be addressed. Everyone is responsible for their actions. If say the nurse on shift has been there too long and is unable to perform their job adequately under those circumstances but realizes their job asks that of them it is their responsibility to find a way to make it work or find another job more suited to their abilities. Please don't take this to mean I feel anything other that pure respect for doctors and nurses but each person must evaluate themselves and make a decision on their actual conclusions and not only on what they want them to be.

Re:Ummm Personal responsibility?

[jtmach]

Antonio Cromartie? is that you?

Re:Ummm Personal responsibility?

[Imazalil]

Yes, it is the nurses job to double check everything, and from the stats it's obvious that 99.99 percent of the time this happens.

The problem is handling of extreme cases. The nurse is at the end of her/his 8 hour shift when an emergency happens, they have 10 seconds to add medical compound A to Tube B, there are half a dozen other people swarming around doing their part to help the patient, who could be having convulsions or is just flailing around uncontrollably. Yes, it's their job to triple check that they are putting things into the right tube, but under conditions like these it gets easier to make a mistake. For most nurses the adrenaline kicks in and it's all good, but even if 1 in a 10,000 make a mistake that ends up being quite a few people at the end of the year.

These nurses can literally hold someone's life in their hands, but they get less respect and pay that someone pushing clip-art around in PowerPoint all day.

Re:Ummm Personal responsibility?

[Anonymous Coward]

I missed the memo that no matter the question at hand, how big or small, if someone suggests anyone should be personally responsible for doing any part of their job correctly than they're a republican shill.

The suggestion is that the government should do ABSOLUTELY NOTHING about it. Because if the government lifts a finger to help the nurse, thats SOCIALLLIZZZZZMMMMM!!!!

Re:Ummm Personal responsibility?

[thegarbz]

Yeah let's just eliminate a potentially useful safety mechanism because of the simple administrative problem of not having enough of the right tubes laying around. I mean it's not like they cost next to nothing, and could just put in big bunches in every room or anything.

Re:Ummm Personal responsibility?

[g4b]

I don't think that's a sheer administrative problem. Also, this problem can't be viewed globally, it's a local problem, depends on country and healthcare system.

Also I can't really tell how it works in the states.

But in a stress situation you have to eliminate complexity to some extent. Now, we do have different colors, and sometimes even interlocks to learn. However, they are not as numerous as their usage field (which is very complex and can't be always categorized easily). Which can be a good thing. Because you do learn how to use another tube to do the same thing, if a special item is not there, and you are taught to write caution signs with big letters on it.

Having the need of choosing between numerous tubes and pairing them correctly needs way more focus and preparation. It's not like you have time to choose between a Torx and a normal screw. Every holdup can lead to additional stress and making small mistakes leads to insecurity and nervousness in the whole team. Best example for me is intubation tubes, which come in different sizes but mostly only two are used: small for young people and the other one from those normal ones, if you know that I mean.

Even if you have different tubes, actually the position of the tube should indicate whether it goes to the vena cava or not. In that particular case, as far as I have seen some stations do use security caps on the access point. Also, in Austria, nurses are not allowed to administer in corpora without additional education and diploma, which reduces the risk.

In a well administered healthcare center, particular stations would transfer the patient ASAP, too.

It's mostly not about the tubes. Mistakes are mostly made, because people in the healthcare system are tired, overworked, understaffed, and have to make life-death decisions way too often. Also, sueing everything nowadays, which is way more terrible in the states as it is in europe, didn't really help with reduction of mistakes.

I do trust medical service. Sometimes in poor circumstances with a lot less of equipment, doctors make it up with a lot of experience and wisdom and creativity. But it's a human try to keep your body intact. It can even fail, if everything is made correctly. Don't misunderstand me. I do think, you got a point. I do not have the longterm working experience to tell which system is better, I just know, creating secure systems has also a downside, which statistically can be even worse in the end, if things get too complicated.
However the biggest problem in healthcare isn't the tubes. It's the people who in some circumstances are burned out.

tube upgrade

[Anonymous Coward]

you would think the industry would be behind a massive tube upgrade programme - my guess it is just the usual lazy, incompetence we see every day across all sectors.

Oh Great

[Anonymous Coward]

It sounds to me like if these people get their way, insted of a few incidents of some idiot nurse not paying attention and hooking up the wrong tube we'll get double (or more) the amount of deaths/injuries because they won't be able to find the right tube for the connection. Brilliant! Heres a simple solution, COLORCODE THE STUPID THINGS, a couple bucks of colored electrical tape and some new procedures would solve most of the problems.

Re:Oh Great

[Anonymous Coward]

It sounds to me like if these people get their way, insted of a few incidents of some idiot nurse not paying attention and hooking up the wrong tube we'll get double (or more) the amount of deaths/injuries because they won't be able to find the right tube for the connection.

That doesn't even make sense you fucking idiot.

Lawsuits

[fermion]

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 acquisition and storage. And of course health care professionals will have to be trained to the point of automaticy to use the proper tubes for each purpose.

It may be that the solution is to simply hire more nurses and the like and to cut down on the overtime that lead to the mistake. Again, it will cost more on the front end for labor, but at least the lawsuits will decrease.

Poka-Yoke

[amstrad]

Sounds like they're in need of a Poka-Yoke project.

Sounds like media fishing for a story

[CatsupBoy]

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.

Re:Sounds like media fishing for a story

[kenh]

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 error (over-worked staff, poor working conditions, lack of training, poorly communicated instructions, someone "helping out" in an area they aren't qualified in, etc.)... True, if the tubes were differnt shapes/colors/sizes these mistakes woul dbe harder, but that buries the contributing factor (sleep deprivation, etc. that will simply cause problems elsewhere).

A good carpenter never blames his tools.

Re:Sounds like media fishing for a story

[mcgrew]

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, 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.

Re:Sounds like media fishing for a story

[Anonymous Coward]

That's not the only unsympathetic part for me.

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."

I mean, I glanced through the article and I found this.

The F.D.A. was so concerned about the application that it inspected the Multi-Med plant in September and issued a warning letter for Multi-Med’s failure to test or design its pediatric feeding tubes adequately.

And uh..this thing.

An F.D.A. manager overruled Dr. McBryde, saying Multi-Med’s tubing was no more dangerous than tubes already on the market.

McBryde's an FDA investigator fyi.

The F.D.A. is in the midst of a wide-ranging reassessment of its device approval process and released a report Aug. 4 that highlighted some of its flaws, including approvals of devices modeled on unsafe or obsolete predecessors.

So just glancing at it, I have to say the FDA is trying their damndest to shore up their approval process. It takes months to get anything approved or disapproved, and it seems that sometimes even if something is questionable, it can still be approved.

If anything, the FDA should be allowed stricter standards and the ability to enforce said standards. The idea that they could "fix this tubing problem tomorrow" is hyperbole. What the hell constitutes a fix in this? Going to every hospital and telling them to toss out their old tubes then replacing them/demanding they buy new ones? Just getting the rules in to say that "hey let's do it this way from now on!" Because if it's A, nuh-uh no way. If it's B, bureaucracy aside, I can see that happening quickly, although the results would take years to be visible and be quite expensive in retraining everyone to use the new tubes.

Anyhow, if you mandated that every company had to produce better tubes, the costs will increase which'll piss off both hospitals, tube sellers, insurance companies, and the patients. Let's not even mention how the free market enthusiasts would react to this.

I'm rambling here. Cut down to as short as I can get it, I mean the following.

The FDA is probably trying to change things. It takes time. It's terrible and whether they change it or not, people will get mad. Neither side wants to start the change.

Also I don't rightly know how powerful the FDA is. If it's anything like the FCC, it's weak.

Re:Sounds like media fishing for a story

[Anonymous Coward]

My grandmother has been going through a huge medical ordeal lately. While in the hospital they had a scanner where, for every drug administered, the nurse would scan the patient's bracelet and then the drug. If there was a problem (wrong drug, dosage, possible interaction, not ordered, etc.) a warning would appear. It still depended on the nurse to actually run the check but it was obvious that they were well drilled in doing this every time.

Re:Sounds like media fishing for a story

[whoop]

If it's B, bureaucracy aside, I can see that happening quickly, although the results would take years to be visible and be quite expensive in retraining everyone to use the new tubes.

There are relatively few deaths due to mistakes of this nature. And, as having worked in the IT and Medical fields separately, I can say, people will just become much better idiots. Blood pressure lines and IV lines haven't been identical in my ten years in medical, but I can see an idiot getting loads of tape or something to keep it secured to the line because, "It just won't stay on."

My wife had her kidneys removed and it is amazing how many nurses and other staff want her to pee in a cup for them. You can give all the specialized adapters, colors, training, etc, but people will still find a way to be stupid.

Re:Sounds like media fishing for a story

[Anonymous Coward]

While I agree with most of what you wrote, your parting shot:

A good carpenter never blames his tools.

doesn't really apply in this context, unless you are saying that good carpenters' tools are hugely expensive and usually bought by administrators who might not have any carpentry experience and simply go with the lowest bidder.

Re:Sounds like media fishing for a story

[darkmeridian]

But the fix is so obvious and easy. Why not save those hundreds of lives as well as prevent all the other non-fatal incidents where tubes were mixed up? Just imagine all the hundreds of lives you'll save in the future just by setting standards! I mean, we can set the freaking GSM and MPEG standards for cell phones and movies but we can't figure out a common color scheme for life-saving equipment?

Re:Sounds like media fishing for a story

[greed]

If you check, you'll find a good carpenter uses good tools, and more importantly, an appropriate one for the job.

You won't find a good carpenter putting a nail in with a circular saw. Or using a hammer to drive in a screw.

A good carpenter will be adaptable: if he needs to take a bit off the edge of a door, he'll be able to use a hand-plane, jointer, table saw, radial arm saw, belt sander, portable power planer, and so on.

But that's not the same as someone's dad handing them a metal-bodied electric drill with sparks coming out of the vents, setting sawdust on fire, and asking them to cut a straight line in a piece of plywood, telling them, "A good carpenter never blames his tools." A good carpenter doesn't get into that situation in the first place.

Re:Sounds like media fishing for a story

[Anonymous Coward]

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

I believe the claim was literal - these particular researchers attributed those deaths to tube mix-ups. The actual number of mistake-caused deaths will be higher because 1) the researchers certainly didn't perform exhaustive research of every medical facility in the country, 2) the tendency to not report these sort of mishaps is extremely high, and 3) there are many other types of fatal mistakes (such as mistaken dosages, wrong patient mistakes, etc). So the number can be multiplied quite significantly. Hard to tell what the appropriate scale factor is. Needless to say, however, any needless death should be prevented if it can be done so by something as simple as better designed tubing.

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.

You're lucky. I've had a couple elderly relatives fall prey to embolisms due to empty IVs (before auto-shutoff delivery). The doctor who delivered me almost killed me and my mom because he couldn't distinguish inches and cm (my head was measured in one, my mother the other). That guy lost his license later. My dad almost got nailed by a nurse who was going to re-use tubing between medications that, if mixed, can sediment out with significant complications potentially including death. My wife could have gotten in trouble when a nurse told me they wouldn't be concerned about her fever (after childbirth) until it reached 105F - turned out that was supposed to be 100.5 and she didn't know the difference. Fortunately I did.

I've seen no end of trouble due to undertrained, and likely overworked, nurses and doctors.

Re:Sounds like media fishing for a story

[pclminion]

You wouldn't think that if your son was one of the hundreds of deaths.

If his son was one of those deaths, then he probably wouldn't be the most objective person to ask, would he?

Re:Sounds like media fishing for a story

[zzsmirkzz]

True, if the tubes were differnt shapes/colors/sizes these mistakes woul dbe harder, but that buries the contributing factor (sleep deprivation, etc. that will simply cause problems elsewhere).

The point of making them different shapes/sizes would be to make these mistakes impossible not just harder. Please note that I said mistake, if you engineer a way to make a square peg fit in a round hole and it kills someone, you're going to be hard pressed to say that what you did was just a 'mistake'. The other thing I want to point out is that I agree by making these mistakes harder/impossible it might hide the other contributing factors that led to the mistake which could lead to other mistakes in different areas; the difference being, that those other mistakes might not be as life-threatening as this one which is plainly easy to fix but probably very costly.

Re:Sounds like media fishing for a story

[thegarbz]

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

There fixed that for you. Now ask yourself this, would your response still the be "hey people screw up and get others killed, meh." if your son was one of the 100s?

It's one thing to say 100s of people die every 40 years due to coconuts falling on their heads, but quite another to say 100s of people die every 40 years due bureaucracy and lack of standardisation.

As an aside from my looking into this it doesn't seem the problem is with the layman, but rather with a complete lack of industry standardisation. One IV comes with a clear tube and the O2 tube is blue, congrads, the next hospital owns a different machine with an airhose that's the same colour as the IV. There is no INDUSTRY standardisation, just like before about 1998 how many times did you accidentally plug the speakers into the headphone socket because you couldn't remember which of the 5 identically coloured holes it goes into? These days your logitech speakers come with a green connector on the end, as does your gigabyte motherboard.

Long nursing shifts

[Anonymous Coward]

Color coding and incompatible connectors are probably good ideas. However, there is a serious issue that probably plays into problems like this. Nurses normally work 10-12 hour shifts. There is no way you are still on you "a-game" after working for the past 11 hours. As you tire, it is easy to start making simple mistakes like these. I'm surprised this hasn't been regulated already. I understand people want long shifts so they can have more days off, but this is probably not a field that should have the option.

Re:Long nursing shifts

[tibit]

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

[radtea]

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

[tibit]

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:Long nursing shifts

[captainlavender]

10-12 hours? Dude, as an intern you sometimes are required to do things like a 24-hours shift, 12 hours off, then 24 hours more. It's among the stupidest things I have ever heard. But good news! Now there's a 30-consecutive-hour limit! http://www.news.harvard.edu/gazette/2006/09.14/99-sleepyinterns.html Hooray for safety...

Re:Long nursing shifts

[SlashBugs]

I know a lot of doctors and medical students in the UK (although they're all from two or three hospitals), and can tell you that these communication skills are a huge part of the modern curriculum. Hearing the younger doctors talk to each other about work, it's obvious that some of the information exchange is formulaic; they've had standardised patterns of communication drilled into them to make sure that everything about a case is put across. In formal settings, this "protocol" includes error-checking, i.e. making sure that the recipient has understood the message.As part of this, the responsibility for communication has shifted: If e.g. information is lost when a doctor talks to a nurse, the doctor is responsible for failing to communicate effectively, rather than the nurse being responsible for misunderstanding.

Re:Long nursing shifts

[demonlapin]

Pilots and nuclear plant operators are trained for it

Nuclear plant operators work at the same plant every day. Pilots on long journeys don't go to sleep in a 747 and wake up in an unknown vehicle that probably is an A300, but then again might be a 767. Effectively communicating an entire patient history is difficult - really difficult. You never really know what details you get that will turn out to be important. It's not surprising that we haven't gotten it down perfectly.

Re:Long nursing shifts

[ramsun]

I just returned home yesterday after a week in the hospital following a 9-hour surgery, so have some context for this.

When my attending nurse was signing out of his/her shift, he/she would come in with all my files into my room, with his/her replacement, and spend up to 20 minutes going through a very detailed handover. They were so efficient at it that even a casual remark by the doctor, "Get him a shave, he'll fell better" was passed on by the night nurse to the day nurse so that they could call the hospital barber.

Granted, this was in India, not in the US, but I was impressed by the detailed communications.

Re:Long nursing shifts

[Anonymous Coward]

Are these the sort of things that doctors have never heard about?

http://teamstepps.ahrq.gov/

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

Re:Long nursing shifts

[compro01]

For comparison, truck drivers aren't allowed to drive for more than 11 hours a day (14 hours on duty) with a required 10 hours downtime, with a limit of 60/70 hours on duty per 7/8 days.

Re:Long nursing shifts

[tibit]

This is very, very interesting. Me & my wife have been to U.S. hospitals for surgeries and if something like this had happened, it was very well hidden. Kept secret, almost. With no practical indication of it ever occurring.

Then where will nurses work?

[kenh]

From the excerpt above:

'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.

How can an operating room be made 100% safe? Nurses go to school to learn how to work in such an environemnt. If, after years of training and working in the field they can't be relied on to know what they are doing, then what was the point of all that expensive training?

If an operating room is to be brought down to the level that anyone can assist the doctor, then nurses are irrelevant - if every pill has to be a different color, shape or size, if every tube, connection, and device needs to be a size incompatible with anything else in the room, and if all the sharp pointy tools need to have safety guards, then what have we accomplished?

Medical mistakes happen, and they always will happen, because of the humans in the process - people have bad days, make mistakes, get tired, get bad instructions, etc - but I for one, am not ready to submit myself to a CNC-style surgical machine without a human operator controling the blade, dosing me with medications from a spreadsheet, or making diagnosis via an online questionaire - I want people in the process, mistakes and all. Besides, I think the number of preventable human errors looks huge, until you realize how many times things go right - for every procedure with tens or hundred of errors per year, I suspect there are thousands or tens of thousands of similar procedures that are performed without incident - daily.

How many times do nurses manage to find the right receptical for the hoses? Gather and dose the proper medication in the proper amount? On a global scale I suspect it is on the order of billions of times a week...

Re:Then where will nurses work?

[Anonymous Coward]

Medical mistakes happen, and they always will happen, because of the humans in the process - people have bad days, make mistakes, get tired, get bad instructions, etc - but I for one, am not ready to

do anything about it because I think the people who get killed deserved it for showing up at the hospital on a bad day with sleepy nurses misreading the charts and screwing up.

FTFY, since you blabbered on without explaining how you really felt.

Re:Then where will nurses work?

[Anonymous Coward]

lolwut?

Re:Then where will nurses work?

[Ken D]

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:Then where will nurses work?

[curare19]

Insinuating that foolproof-designed medical equipment eliminates the need for medical training (and therefore surgery can be assisted "by anyone", as you claim) is akin to claiming that a debugger eliminates the need to learn proper software development procedures and programming protocols.
Training, no matter how extensive, doesn't eliminate human error. Stress, lack of sleep, long hours, distractions, and high pressure environments can all contribute to human error - and as we all know, those are common working conditions in hospitals.

Re:Then where will nurses work?

[whoop]

And as we saw in a recent article, people get lazy, skip checklists, and planes still crash.

Build a better system, the world will build better idiots.

Re:Then where will nurses work?

[mcgrew]

If, after years of training and working in the field they can't be relied on to know what they are doing, then what was the point of all that expensive training?

Learning which tubes to stick in which orifice is the least of a nurse's training. They have to know about drugs, drug interactions, chemistry (one of the things they do in a 101 level class is learn to make aspirin), anatomy, pathogens, all sorts of stuff.

The nurse doesn't empty your bedpan, a nurse's aide does that. Even that takes a few weeks of training*.

Medical mistakes happen, and they always will happen, because of the humans in the process - people have bad days, make mistakes, get tired, get bad instructions, etc

That statement illustrates the need to follow the KISS principle of engineering -- "Keep It Simple, Stupid". The easier it is for medical personnel to do their jobs, the safer you are in a hospital. Not making a place where you're supposed to get well as safe as possible is stupid.

I for one, am not ready to submit myself to a CNC-style surgical machine without a human operator controling the blade, dosing me with medications from a spreadsheet, or making diagnosis via an online questionaire

It's not done like that because it would be more dangerous. Nobody's advocating that untrained personnel plug the hoses in, only that it's made harder for the medical staff to screw up.

How many times do nurses manage to find the right receptical for the hoses?

My dad's wisdom: "One 'oh, shit' wipes out a whole bunch of 'attaboys'". And an "oh, shit" that kills or maims someone is a BIG "oh, shit". Reducing the possibility of error is just common sense. That's why when I had a vitrectomy they put a dot over my left eye to make sure the surgeon didn't stick needles in the wrong eye, and my name on my neck so they didn't confuse me with another patient and perform an enucleation or something.

* Evil-X was a nurse's aide, my friend Amy was an LPN, who doesn't have to know as much as an RN, who doesn't have to know as much as a medical doctor.

Re:Then where will nurses work?

[maxwell demon]

So you are saying that because we cannot eliminate all errors, we should eliminate none?

Re:Then where will nurses work?

[Anonymous Coward]

You might want to also throw in an appeal to "just think of the children" while you're at it.

Re:Then where will nurses work?

[lucian1900]

You're looking in the wrong place. As long as people die of preventable mistakes, it doesn't matter how many times everything goes well. Dummy-proof equipment is always a good idea if it allows professionals the flexibility they require. And in this case, that's not an issue.

Couldn't resist

[Anonymous Coward]

"killing a 16-year-old who was giving birth"

I bet that saved the state a lot in welfare payments.

Re:Couldn't resist

[iamhassi]

+1, Insightful

here's the news article about the 16 yr old's death and 1.9 million dollar settlement. Money goes to the baby, so now the grandparents and boy's father are fighting over the child. For once no one is thinking of the children.

Parallels with computer cabling

[goodmanj]

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

[Obyron]

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.

Re:Parallels with computer cabling

[Anonymous Coward]

> 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?

You obviously never worked with the Amiga. Commodore put +5vDC on an RS-232 connector. It was in support of their brain-damaged daisy-chain external devices. Inherited from the C64 were they? Also, I remember losing a TRS-80 to a moron who plugged the power supply into the tape I/O port.

"... if the plug fits in the jack, it should work." I'm guessing you work at "Chester's 'puter 'pair", just over there, turn left on the dirt road...

Re:Parallels with computer cabling

[tomhudson]

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.

True story:

"I just put half a tank of diesel in the car. What should I do?"
Me: "Fill it right to the top with gasoline, then drive. Wnen you've used up a couple of gallons, top it off again. Repeat every day."
"Will that work?"
Me: "You better hope so! It's 20 below!"

So yes, people can fill their gas tanks with diesel. And yes, it worked. #1 diesel (winter months uses a thinner grade to prevent wax build-up) is lighter than #2 diesel. The exhaust smelled like an old bus, but it worked.

Re:Parallels with computer cabling

[petermgreen]

remember ps/2 mouse/keyboard ports?
Well they didn't blow up, they just didn't tend to work due to the controller manufacturers being too lazy to make them work either way round (and yes it is possible to detect the difference, laptops did it for years).

RS-232 and PC printer ports used the same connectors but the PC ends had opposite genders so you'd have to go pretty out of your way to hook things up wrong with those.

So really unless you are using special stuff (e.g. external SCSI with it's myriad of conenctor some of which are shared with other stuff or data aquisition cards which tend to use whatever connector they can get enough pins out on) it's been pretty hard to make any really bad mixups with external PC connectors for a long time.

Internal PC connectors on the other hand often seem to be plain pin headers, usually withotu even any polarisation keys and often with the need to plug many small connectors onto. Still it's not as bad as it used to be where you had to plug in two power connectors of the same type next to each other and if you got them the wrong way round it almost certainly meant a fried motherboard.

Re:Parallels with computer cabling

[Anonymous Coward]

yea they are on my brand new computer, and I have never once seen a computer or keyboard "blow up" cause I plugged it into the mouse port

I quit reading at that point, seems like your a bright person to bring up a point that is null, so why waste my time as you go off into medical land which your qualified for

Re:Parallels with computer cabling

[Anonymous Coward]

Remember when PS2 became the defacto standard for mouse and keyboard connectivity? Remember the issues with people plugging the connectors into the wrong port? (Ok, it wasn't killing people, but bear with me). The PC industry quickly began to color code the connectors and ports, making keyboard and mouse installation "so easy even a caveman could do it"(tm). There is no logical reason this approach cannot be applied to this situation. Adopt an international color scheme, some colors are already in use like green for oxygen. Match the colors and you're ok. Government approvals for just color changes shouldn't be too difficult (Ok I know, we are talking about governments here). Manufacturers will follow the money and if large hospital associations buy only from companies supplying tubing with color-coded fittings, the others will follow suit. Very quickly it will be difficult to find tubing without color-coded fittings. Simplistic? Perhaps, but simple is almost always better.

Re:Parallels with computer cabling

[drinkypoo]

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

Oh yeah, gas stations. Let's see, if you put diesel in your gas car, odds are it just won't run. But if you put gas in your diesel, it will fuck it all up. Yet you can easily put the gas nozzle into the diesel tank, but you can't put the diesel nozzle into your gas tank. Maybe you should just put down the keyboard, and back away slowly.

(Doesn't work the other way around, of course, but diesel users are in the minority, and can be assumed to be paying attention.)

That's bullshit, we're talking right here about people who can be assumed to be paying attention fucking up and killing people. You're talking pure nonsense. You even know right here that it's a shitty example and you say so ("of course") but instead of stopping and rewriting your comment to make sense, you just kept going.

Re:Parallels with computer cabling

[multipartmixed]

>> remember ps/2 mouse/keyboard ports?
> Well they didn't blow up, they just didn't tend to work

That wasn't always true. As a PC tech in the early 90s, I replaced many keyboard fuses which were blown because people plugged mouses into them.

One guy was such a tool that I installed an external fuse holder on his chassis so that he could install a fresh bus fuse every time he did that.

Re:Parallels with computer cabling

[jimicus]

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

Bit of a shame, then, that putting diesel in a petrol-engined vehicle is a relatively minor annoyance. The other way around, however, can screw up a diesel engine royally.

Re:Parallels with computer cabling

[Anonymous Coward]

"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."

You know, you say this, but just the other day I filled my CRV with diesel and was not happy about having to drain and dispose of it. Turns out both the handles were black, and the diesel filler tube DOES IN FACT fit into a gasoline tank's opening. That's the thing about generalizations, someone somewhere will always have a counter-example...

Re:Parallels with computer cabling

[Anonymous Coward]

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.

Or you could just apply the tint to the outside of the tubing. Or even etch a word or phrase like "oxygen" over and over along the length of the tubing.

Re:Parallels with computer cabling

[Anonymous Coward]

um they are electrically compatible, always has been, the only difference is the software protocol

Re:Parallels with computer cabling

[conejo especial]

Small manufacturers can make a fortune just selling backwards compatibility adapters.

Making adapters completely negates the value/safety of creating a standard for tubing ends... but no adapters means introducing SOME new tubing means replacing ALL the old stuff, which would be kind of expensive. That's sort of a catch-22.

Re:Parallels with computer cabling

[bugs2squash]

You're right, it should all be replaced with a wireless solution.

Re:Parallels with computer cabling

[goodmanj]

Yeah, I thought about that. Same is true in the computer world: I'm sure someone, somewhere, will sell you a perfectly reasonable set of adapters that will let you send 120 volts AC into an Ethernet jack.

Adapters are a necessary evil: they allow people to mix old crap with new and better stuff, but without them, we'd be stuck with the old crap forever.

Re:Parallels with computer cabling

[goodmanj]

"... if the plug fits in the jack, it should work." I'm guessing you work at "Chester's 'puter 'pair", just over there, turn left on the dirt road...

As I said, "didn't used to be like this". Computer engineers have learned a lot about idiot-proofing since idiots started buying computers.

And medical equipment designers are going to have to learn a lot now that idiots are becoming nurses. Seriously, have you *seen* some of the people going to nursing school these days?

Anyway, find me a modern case where the plug fits in the jack but the result is catastrophic failure, and we'll talk.

Re:Parallels with computer cabling

[Anonymous Coward]

...a battery of tests showing that the color tinting will not leach out of the line...

How about just putting a tinted outer layer around the existing transparent tubes?

Re:Parallels with computer cabling

[Idarubicin]

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.

It makes sense

[kannibal_klown]

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 obscure the compound a little since it's not as transparent. Plus there are only so many colors they could use without dealing with color-blindness or some other near-color issue (is this blue or purple). And lastly, since there are only so many colors they can use, then confusion can still occur and be worse if you're dealing with a pink fluid going through a pink tube... which is which.

The other thing I can think of is different kinds of connections/slots. However then you have an over-engineered tube instead of a plain cylinder-into-cylinder tube which is easier to maintain and doesn't need replacing as much.

So it's not a no-brainer fix, since the fixes themselves aren't perfect and introduce other issues.Though I agree, something more should be done since during emergency or stressful times even an experienced nurse can make a mistake if there are enough tubes around.

Re:It makes sense

[goodmanj]

In my opinion, "over-engineering" isn't a problem where medical devices are concerned. With a price of $5-10 dollars for a couple of grams of plastic, manufactured by the millions, the profit margin on these makes aftermarket USB cable vendors look like chumps.

You can afford to spend a little extra money making a square or hexagonal fitting, a threaded connector with a particular diameter and thread gauge, etc.

If your IV tubing ends up costing a little more than your competitors, no problem. Just ask your customers how the money they save going with your competitor compares with the price of a malpractice settlement.

Re:It makes sense

[goodmanj]

OK, I take that back. It *is* possible to over-engineer medical devices. See this post.

If filling stations can do it...

[AlecC]

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 for a 98% solution, just requiring someone to take the lead.

LEAN Manufacturing Principles

[Pilon]

It's called Poka-yoke from the Lean manufacturing world: http://en.wikipedia.org/wiki/Poka-yoke

Just this Week

[Anonymous Coward]

Just this week - news in Sydney, chlorhexidine as an epidural, shudder the thought >.
http://www.smh.com.au/nsw/how-could-this-happen-hospital-blunder-turns-a-familys-joy-into-heartbreak-20100820-138xw.html
Human error it seems, not following correct procedure - and yeah, she's fucked up.

Murphy's law

[Anonymous Coward]

This is the definition of Murphy's law, right?

RFID

[Joebert]

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:RFID

[goodmanj]

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

You just proved me wrong.

Re:RFID

[jeff4747]

Because when a patient has many tubes coming out of them, those tubes won't be in close proximity and constantly sounding the alarm.

Re:RFID

[Dunbal]

An alarm that sounds all the time is completely useless and in itself can do more harm than good. Ask the ghosts of these pilots.

Pun potential detected

[dark_panda]

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

A good book that speaks to this

[Anonymous Coward]

Here is a very good book that covers many of the same issues. The human factor: revolutionizing the way people live with technology By Kim J. Vicente

Checking Out STAT

[Anonymous Coward]

At one hospital I know, a nurse gave a patient kaopectate intravenously.

In a bit of foot-in-mouth disease only I am capable of, one night I told this story at a party only to discover later that the hospital admin who'd been in charge at the time was one of my listeners.

Rural? Be afraid, be very afraid

[Ultimate Heretic]

As a sibling of a couple of physicians, I get to hear a lot about the quality of personnel in small and rural hospitals. In general, the advice I have been given is that unless I am about to expire, I am to head for the nearest large city and a hospital therein. Why? The spectrum of support staff at smaller, more isolated hospitals tends to the lower end in skill. It is unfortunate intersection of cost (cannot pay as well in small cities/hospitals) and availability of better trained staff. As an outsider, I see this as partly due to the increase of turning many formally well trained support positions into ones held by what the human resources want to term as 'technicians'. Nothing wrong with being a tech, but the push is for the lowest training and therefore lowest cost. After all, the machine cannot make a mistake and anyone can hook up the tube/insert the sample/draw the blood/distribute the medicine, etc. However, complete ignorance of the meaning of test results/medical weights an measures/meaning of standards, etc. leads to some funny results (deadly, not ha ha). In essence, if you or an advocate (family or friends) are not on duty 24/7, you can be at the mercy of mistakes through ignorance, negligence or simply chance. YMMV.

Is the alternative better then?

[Errol backfiring]

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.

Really?

[kenh]

'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.

Yeah, right - the FDA is simply a rubber-stamp for the mdical industry... You have to be painfully ignorant of the medical field to make such statement.

We really want the FDA to regulate the size, color, and style of connecotrs on all medical devices? Seriously? We can't trust doctors with surgical tubing any more?

That sounds expensive, especially when you factor in the cost of all the CYA expenses to protect hospitals/medical providers from federal fines and penalties...

ha hah hahha ahaa hhha ha ha haahhaa

[Jodka]

'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."

As someone who works in the medical device industry, let me say, that statement is preposterous. The FDA is not worried about "making the industry happy." First, to the extent that FDA has a bias, it is staffed with anti-corporate zealots who believe that making a profit from the sick and dying is unethical and are out to make the industry unhappy. Secondly, there is no reason whatsoever that this initiative has to come from the government. Just like 802.11, firewire, bluetooth and every POSIX did not come from a government agency, neither would a tubing standard. Third, selling specialized tubing products to hospitals would be more, not less profitable than commodity tubing products. Fourth, if the industry did create a standard, the barriers to developing and deploying that would be the FDA. Rule of thumb is that the cost of bringing a product to market is about 10X under FDA regulation than not and delays in FDA approval can be several years.

We don't HAVE to surrender to our situations

[FranTaylor]

Whatever has happened to personal responsibility?

Well of course, but since we humans have control over our situations and our lives, we can prepare our situations so that the risk of errors is minimized.

Example: due to a poor user interface, a pilot programs the autopilot to fly into the side of a mountain (yes this really happened). Of course it is a user error, but the designers of the autopilot STILL took the effort to redesign the user interface.

And as far as "personal responsibility" goes, well the pilot is dead, so good luck teaching them a lesson.

Re:We don't HAVE to surrender to our situations

[realsilly]

The design of the tubes work as intended. An when you're trained to work as a nurse, this is part of the job. You must check and re-check, because people's lives are at stake. I would venture to guess, that the tubes have been designed to be the same shape and size so as to help keep the amount of medicine more easily regulated. If you have color coded tubes, that works if you are no color blind. But even color coded tubes or labeled tubes won't prevent people (the human factor) from making mistakes.

It is true in every industry that people are over worked and make mistakes. But this is directly dealing with people and helping to make them better. Would you argue the same point if some tired overworked programmer messed up a decimal point in a program and the $1000 dollars of your hard earned money only looked like $10 dollars on all receipts. Maybe that $1000 dollars is what is needed to pay for the medicine to say your family member. Would you treat that programmer the same way as a tired over worked nurse? Probably not.

Personal responsibility exists in all areas of society. It's called integrety. If you're over worked and can't handle the job, take a day off. But people don't for all sorts of reasons. They need the cash is one of the biggest reasons. So lets think about this from the bigger picture. Personal responsibility is everyone's own responsibility. We as people need to know how to say when we need a break or help. Then and only then can the industries really see where the flaws are in their systems to begin to provide better support to those individuals.

Re:We don't HAVE to surrender to our situations

[Dragoness Eclectic]

If you're over worked and can't handle the job, take a day off. But people don't for all sorts of reasons. They need the cash is one of the biggest reasons. So lets think about this from the bigger picture. Personal responsibility is everyone's own responsibility. We as people need to know how to say when we need a break or help. Then and only then can the industries really see where the flaws are in their systems to begin to provide better support to those individuals.

You seem a trifle naive about the work conditions on some jobs. People have to eat and pay the rent, so if telling the boss they can't do the job at the pace they're required to is likely to get them fired or "let go" for underperformance ("not a team player" is another classic), they'll just keep their mouths shut and work around the problem. They may be rushed, they make take shortcuts, they may dump the entire mail shipment in a ravine and mark it as delivered, but they will do what it takes for them to survive. Or, they may just snap one day.

In a bad economy, where jobs are hard to find and there's a hundred people who'd love to have your job, you are not going to tell your boss you need a break or can't keep up the pace.

Re:We don't HAVE to surrender to our situations

[maxwell demon]

Would you treat that programmer the same way as a tired over worked nurse? Probably not.

And yet we have in programming "incompatible tubes". It's called strong typing. And it's exactly there in order to prevent programmer errors. And yes, there are ways to "it incompatible tubes together" (known as typecasting). And sure as hell some people use this to fit together "wrong tubes" and produce bugs waiting to happen. Yet most people would agree that in general strong typing reduces the number of errors which slip through.

From the manufacturing side

[Anonymous Coward]

I work on the manufacturing end of the medical devices industry. It would take a massive change to alter this. Most of the parts we make are interconnect-able by design, so that individual valves, fittings, and devices can be assembled into the set that is needed. These systems are not as pre-engineered as everyone thinks they are. Some sets are standard, but many are custom made according to the hospital's requirements. And these are still just components of a larger system assembled on-site. Most tubing sets are terminated with a luer-taper (wikipedia) connection (the standard connection on the end of a syringe - not the needle). This allows interconnection with other devices. Even if you were to change the end connections, a side port with a luer taper connection would always be required by hospitals so that a syringe could be used to access the line. Color coding could possibly help. The best solution would be to leave the sets as-is and at the hospital tag each with an obvious colored label as it is installed/assembled.

Compared to the computer industry

[picoboy]

At some point these medical manufacturers need to organize themselves into standards bodies or else the government will do it for them. Perhaps the problem is that the medical equipment manufacturers don't have the same cultural view that their counterparts in the computer industry have (Apple excluded, of course) that standards are beneficial to their business. I'm not exactly sure why this is, perhaps others closer to the medical equipment industry have better insight. But I suspect that it isn't as easy to fix as many of us slashdotters (read computer geeks) dismissively suggest because it is more dependent on culture and politics, not technology.

It's society's fault!

[Dunbal]

Nurses should not have to work in an environment where it is even possible to make that kind of mistake

      Speaking as a physician, it's your responsibility to know exactly what you're doing. Blaming "the environment" is just making excuses for gross negligence. Just like it's wise to double-check the medication you are dispensing, double-check the dose you are administering if it's a substance with dangerous side effects, and screen your patients before surgery (instead of doing it the way we used to pre 1980's, when a significant number of patients died on the table because they had unknown underlying conditions we would find out about in the autopsy), you should make sure that you're performing a procedure correctly. If you don't do that, I suggest another line of work.

Re:It's society's fault!

[Oxygen99]

Yeah, but that's bobbins though, isn't it? There's a reason airplane cockpits are designed the way they are. There's a reason nuclear power station control surfaces are designed the way they are. In fact there's a very good reason why anything that could really go bang has input devices that are designed to diminish the possibility of user error.

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.

Re:It's society's fault!

[Dunbal]

No-one, not you, certainly not me, can attend exactly to what they're doing for every second of every minute of every day.

      Agreed - and you don't have to do it every second of every minute of every day. Just when you're about to perform a procedure. There's a reason pilots have pre-flight checklists, and I'm sure those who work in nuclear reactors have a script to follow. In fact, just about any "mission critical" aspect of any job is written on paper. You can do things on "autopilot" without paying attention to what you do most of the time, but for some tasks you need to be sure of what you're doing. That means paying a little more attention than normal. After all, these "accidents" are in fact manslaughter. I certainly bear that in mind every time I write a prescription or perform a procedure - no matter how trivial. Primum non nocere...

Re:It's society's fault!

[Krahar]

Everyone makes mistakes and pretending otherwise is pure delusion. There is no amount of trying to pay attention that lowers risk of mistakes to 0%. If equipment can reasonable be made such that people don't die when the inevitable mistakes happen, then make the equipment like that.

Re:It's society's fault!

[Dunbal]

There is no amount of trying to pay attention that lowers risk of mistakes to 0%.

      Not 0%, but as close to it as possible.

      However the situations described are not under the same conditions as a pilot dealing with an emergency 100 feet off the runway at 200 knots. They are utter carelessness - failing to check to see which IV lead was being used in some circumstances. It takes no time at all to move a blanket out of the way and actually look.

      So, instead of addressing the core issue which is the incorrect technique being used by nursing staff, some would rather outsource the problem and blame it on the manufacturers, cause new equipment to be designed and new "foolproof" standards to be adopted. And yet guess who ends up paying for this? You, the patient, and you the taxpayer. Why? Because some people are too lazy to do their damned jobs properly.

      I vehemently disagree. Because even after these new mechanisms were developed, there would STILL be an error margin above 0%. Like Douglas Adams once wrote: "A common mistake that people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools". I disagree that nurses should be allowed to abandon the use of their brains in favor of an over-engineered, expensive piece of machinery that wouldn't exist to increase our knowledge about patients or permit us to do things we can't do now - just permit idiots to keep jobs that they shouldn't have in the first place.

      If you don't know what you're doing and why you are doing it, you have no place performing medical procedures on a patient. If we manage to design foolproof systems, why have trained nurses at all? Hire minimum wage workers to do it. Right?

Re:It's society's fault!

[Krahar]

You seem to be advocating introducing mistake-prone procedures to be able to punish the nurses who then make mistakes. I think killing patients just to be able to punish the nurses who weren't able to prevent it is rather a strange idea, though I acknowledge that it would help in identifying which nurses are better able to prevent the mistake-prone procedure from killing patients.

Re:It's society's fault!

[Dunbal]

No, I am advocating doing procedures the right way to start with. Then they are not "mistake prone" and no one gets killed. If you build safety into your routine, you avoid mistakes. These mistakes are negligence, not because there's anything difficult about the procedure itself or the equipment. You are siding with those who are looking for something to blame other than themselves. People who make the least effort and don't pay attention to what they're doing. This is not who I want taking care of me.

You want to invest time and resources to come up with better equipment that monkeys can use. I want to invest time and resources to train people better, to make sure I hired the right people and pay them well. Hey this is nursing, not brain surgery. There's nothing particularly more difficult about administering an IV medication than making sure you're putting your shirt on the right way around or making sure your socks match. People manage to do those things every day. Of course if you never check what you're doing, well, it's bound to happen one day.

Re:It's society's fault!

[Krahar]

Doing procedures the right way every time is not an option because anything a human does carries a risk of mistake. There are better ways of identifying incompetent nurses than letting them kill patients and then fire them for it.

what the bleep are you talking about?

[FranTaylor]

dude have you never swapped the ps2 keyboard and mouse cables and wondered why neither works?

interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?

why on earth do i need a sata/e-sata adapter?

please make a list of all the USB connectors and their purpose

go on find a new power supply for your external drive enclosure

the computing industry is VERY POOR at good connector design

Re:what the bleep are you talking about?

[operagost]

He mentioned the PS/2 ports. Weren't you paying attention? And those were designed in the 1980s and are obsolete.

interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?

Nothing, because it's not making good contact. And if it's the dual-purpose jack that does, again, nothing.

please make a list of all the USB connectors and their purpose

To make USB connections. There are different ones because some are for hosts, some for devices, and some for space considerations (or would you rather have a huge type B connector on your phone).

go on find a new power supply for your external drive enclosure

That's not an everyday situation, is it? It's quite simple to read the numbers and illustration next to the power jack or on the label and build a power supply-- if you know what you're doing. What does anything you've listed have to do with having incompatible connectors for safety reasons, anyway?

Re:what the bleep are you talking about?

[drinkypoo]

He mentioned the PS/2 ports. Weren't you paying attention? And those were designed in the 1980s and are obsolete.

Why do they keep putting them on all my new motherboards, then? Why do they keep putting them on all non-tiny desktop computers? If any of you ever used any good Intel boards, you'd know that some boards allow you to interchange them. It's a shitty example anyway. Now, we could go back in time and talk about Apple using DB15 connectors for monitors...

interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?

Nothing, because it's not making good contact. And if it's the dual-purpose jack that does, again, nothing.

Uh, an RJ11 makes GREAT contact with an RJ45 jack... on the center pins. I've often had phones plugged in this way. It's actually a design feature of the jack. I don't know what happens, though. The current levels on a phone are pretty low, but the voltage IS four times that of ethernet. I'd suspect that a quality NIC will make it and a crappy one will die.

To make USB connections. There are different ones because some are for hosts, some for devices, and some for space considerations (or would you rather have a huge type B connector on your phone).

There should be two USB connectors; USB-micro with its added leads for video and whatnot, and USB-A. That's it. Lots of devices have a USB-A jack on them, the USB-B jack doesn't even need to exist. The only time it's ever made sense for connectors to be different on each end is when it was SOP for all devices to be pinned opposite from the host so that you could always use a cable as an extension cable. Those days are over.

go on find a new power supply for your external drive enclosure

That's not an everyday situation, is it? It's quite simple to read the numbers and illustration next to the power jack or on the label and build a power supply-- if you know what you're doing.

Not really. Sometimes there is no pinout. In fact I have four external enclosures with two different pinouts and none of the enclosures have a diagram on them, but all the power supplies do. Doesn't help you if you don't know which supply came with which device though. You're talking nonsense... again. Seems to be your hobby, every time I see one of your comments lately it's full of nonsense.

What does anything you've listed have to do with having incompatible connectors for safety reasons, anyway?

There have been computing devices throughout history which will die if you plug them in wrong, and you can do so. Indeed, this is the first time that has not been true; today you can pretty much buy stuff and plug it in where it fits without killing anything. The one exception is the power supply voltage but you won't kill anything in a 120VAC country, they just don't work if they're switched wrong. Some power supplies autoswitch, but that's pretty rare in desktops while it's common in laptops and peripherals.

Re:what the bleep are you talking about?

[multipartmixed]

> interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?

Bad example. RJ-45 was designed so that RJ-11 plugs into it correctly; in fact, some vendors no longer make RJ-11 jacks (BIX) and many places just use RJ-45 DVOs even for POTS phones.

Pair one on the RJ-45 standard is reserved for the telephone. So, you can wire up a phone and an ethernet connection (using pairs 2 and 3) on the same jack. Function is then determined by what device you plug into it.

Why bother messing around with labels?

[Benfea]

The computer industry figured out how to make my USB plugs incompatible with my ethernet jack. More importantly, they did this without the government telling them to. They did it while operating on much narrower profit margins, and without a large number of human lives hanging in the balance.

The idiots running the health care industry should have resolved this on their own a long time ago. The government should not have had to get involved at all.

Re:Why bother messing around with labels?

[TechnoFrood]

Incompatible yes, idiot proof no. I have seen a couple of people who managed to jam a USB plug into the network socket of their laptop.

Re:Why bother messing around with labels?

[Anonymous Coward]

To be fair your beloved computer industry previously had lots of gratuitously incompatible cables too. How many "adaptors" do I own that are purely mechanical? Too many.

Also, stuff like this IS already done in the health care industry, this is just an article about something that hasn't been done so far.

If you compare the apparatus for taking a blood sample fifty years ago with today, it's night and day. Check it out, one use self-contained and pre-labelled containers with a vacuum, so they fill automatically. Each container is a different colour representing the test to be performed, massively reducing the number of recalls "Whoops, we ran test B4 but your doctor actually wanted K35". No risk of blood contamination, and most of the containers (unless it's incompatible with the specific test) are plastic, meaning low breakage risk.

Re:Why bother messing around with labels?

[tophermeyer]

Incompatible yes, idiot proof no. I have seen a couple of people who managed to jam a USB plug into the network socket of their laptop.

Well I'm sorry! Its supposed to be a Universal something-or-other. That means the thingy should work in anything I stick it into or they shouldn't call it that.

OMFW

[hesaigo999ca]

>Nurses should not have to work in an environment where it is even possible to make that kind of mistake,'
>FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die

Ok first off, if I am a nurse and know that there are too many tubes, just like when you are a network admin and have to run cable along, they are not going to make all sorts of different cables for you, YOU have to sort them out, usually with permanent marker or with color tape etc...etc... so if you know some nitwit is working for you not able to first off check which line she is working with by actually making sure where each end meets what.....then you could color code the tubes yellow means blood, green means iv, blue means etc...etc..

Seriously, let's put all the onus on others instead of ourselves, that is so much easier. Instead of owning up to your own mistake, you would think the first death related to this, the nurses would go to the office supply store and buy those stickers and stick them on ALL the tubes to sort them out...

As for the FDA being in someone's pocket, guess what your own President is in someone's pocket, and yet you still vote for them,
we still put up with the media cover up for what BP did, when was the last time we heard anything about THE BIGGEST OIL SPILL IN HISTORY, if I was Obama, I would be talking about this everyday for the next 4 years. Yet he is bought off, the media is bought off....my point is we can only rely on ourselves....so for this situation, the nurses need to just accept the FDA are turds, and they need to step up, and come up with their own system, after all THE NURSES are the ones giving the care, and liable not some tubing company.

Unlikely

[Anonymous Coward]

As a physician, I can say that the summary is extremely misleading (surprising for Slashdot, I know). For instance, there is absolutely no way to connect a blood pressure cuff line to an IV line - they are completely different connections. The same goes for enteral feeding and IV tubing, ditto for oxygen tubing, etc. Also, as someone who works in an ICU, one of the first things that nurses do in any situation where the patient has multiple lines going into their body is label each line. Now obviously if you are determined and stupid, you can physically make two different connections fit (a poster above mentioned a nurse using tape to connect to incompatible lines), but that isn't a problem that will be fixed by color coding the connections.

Re:Unlikely

[demonlapin]

I've seen enteral tubes in the NICU that had Luer ends, and while it's not a BP cuff, our surgical tourniquets connect via Luer. There's some funny stuff out there, if you look. For example, here is a jejunostomy tube with a Luer connector.

Gag orders and agreements should be banned

[n2hightech]

I read the article and came across the same thing I see over and over where someone kills or harms someone due to negligence. In order to get a settlement the harmed party needs to agree to never tell anyone about what happened. This type of secrecy needs to be OUTLAWED! How can people make good market decisions when the facts about quality of care are hidden. Some incompetent quack can merrily go on his way killing or harming person after person as long as he pays his malpractice insurance. The quality of care and many other products and services would improve greatly if people knew that mistakes they make will follow them forever. I would favor a national database freely accessible over the internet of every damage award and the details surrounding it. You go looking for a Dr or a Lawyer or a car mechanic you can at least check to see if they have had problems. Now its tough to know. I also do not understand why the insurance companies are not actively involved in pushing for things that would save them money in claims like the infection stopping check lists or simple color coded tubes and noninterchangable connectors. Stuff we have been doing in the automotive industry for years. Not because some government agency told us too but because it saves money.

Sure, that's a problem

[Benfea]

But the connectors should be incompatible regardless of the hours and stress nurses are subjected to.

Re:because, same for FAA

[schwit1]

Many airport related problems are due to the conflicting mission of the FAA as regulator and promoter of aviation.

Libertarians - I'm confused

[Anonymous Coward]

Shouldn't the free market have already addressed this problem?

Re:Libertarians - I'm confused

[Anonymous Coward]

What problem?

Re:Libertarians - I'm confused

[guruevi]

They have, it's called malpractice insurance and settlements. Hospitals have huge coffins with millions of dollars just for this kind of thing.

Please do NOT just color code them.

[IndustrialComplex]

Please if you are going to go with something to differentiate tubing please go with a simple pattern along with a color coding, considering the 'costs' of what these things cost, I think a 0.1cent cost per tube would be negligible when you consider you might cut nearly 10% of the male population out of the career.

There have already been pushes to make colorblind people ineligible for medical careers, the last thing we need is yet another profession that is barred to us. Colorblindness does NOT count as a disability according to the US Federal Government, but if I have another potential career cut off from me it better damned well be considered a disability.

Re:Please do NOT just color code them.

[lucian1900]

I'm pretty sure the percentage of colourblind males is less than 10. Otherwise, you're right.

Re:Please do NOT just color code them.

[IndustrialComplex]

I'm pretty sure the percentage of colourblind males is less than 10. Otherwise, you're right.

Nearly 10% is less than 10%.

Otherwise, I'm still right ;)

I'm confused...

[kevinNCSU]

If the FDA mandated special-shaped connectors for each category of tubing that ALL hospitals across the USA then had to buy from Industry how would that NOT make industry happy? Are you sure it's Industry that they want happy or is it hospitals with limited budgets that would have to replace all their equipment and thus move funds away from other patient care areas?

Training at fault... not the FDA

[sniperdoc]

I was a Medic in the Navy, and I can tell you that most of these errors are due to training problems. Individuals that just graduated from schools are pushed out onto the wards too soon without proper training on the equipment that is in place and accidents like this happen in high stress situations. As others have stated, a majority of the interfaces of the different tubes are already different, a lot of times they are already color coded, if they're not color coded, they sometimes have colored tape/flex tape on them to differentiate them. Often times people take a 2 year nursing course and don't know shit from shinola. In my 14 weeks of Hospital Corps training at Balboa Hospital and my 5 week Field Med School at Camp Pendleton I've learned more efficiently, faster, and better than most civilian practitioners. My 6-months On-The-Job training when I got to my first command made me more comfortable and proficient at all the things I learned in Corps School. Hell... I diagnosed my wife with Pleurisy without major tests and deductive reasoning when some Doctor intern/resident thought my wife had Adult Onset Asthma... gee... They put her on an inhaler and the breathing pain goes away (even though minutes before, they gave her Demerol before the inhaler treatment). Dumbasses. To hold the FDA responsible for something like this is like saying that Ford/GM/Toyota is at fault for the owner putting gasoline into the oil port or transmission fluid into the Radiator... it comes down to training and being aware. It's training people that's at fault here... not the FDA. The whole article in general is garbage because of that.

Computers

[Anonymous Coward]

Computers stopped dying for this kind of reasons a while ago!

More than one way to skin a cat.

[erevlydeux]

Why not put... stickers on the connector ends and around syringe injection points? The tubing stays clear to see the liquid/gas going through it, no change in chemical composition to satisfy the FDA, but it's still clearly marked: hey, green sticker, this is going into a vein so don't pump air into it. oh, this bad boy has a red sticker, better be an intrathecally administered drug because this is going into someone's spinal cord! If you wanted to up the ante, you could even use certain shapes on the stickers to also indicate their usage, for anybody that happens to be colorblind. The solution seems stupidly simple: better labeling. A lot of people seem to be stonewalling on the color of the tubing, though. There are other ways of labeling the tubing besides coloring the tubing itself.

Re:More than one way to skin a cat.

[jimicus]

Then the argument will shift from "does the dye interfere with anything?" to "does the glue interfere with anything?"

Training and Competence

[wisnoskij]

Sounds likes something a little training and general competence should solve.
And I am guessing no matter how similar they are they are put in separate containers that are clearly labelled.

and since they are deadly if used interchangeably then and I also guessing that they are not all that similar to begin with?

Re:Training and Competence

[marc_the_kiwi]

Sounds likes something a little training and general competence should solve.

I agree completely. How do you screen for incompetent medical professionals?
Sadly, most likely with great difficulty and expense.

Better Architecture can help.

[Anonymous Coward]

These errors also occur not just because of stupidity or human error but because of the left or right handedness of the room. Like hotel and dorm rooms, older designed hospitals have the wet/mechanical walls back to back making patient rooms flip flop as they went down the hall. Consequently the medical gases and and electronics flip flop from one side of the patient bed to the other. Believe it or not, this causes errors.

Now, health organizations realize that the cost of litigation and damages out weigh the savings of building common wet/mech walls. So new hospitals are increasingly being built with identical rooms that do not flip. The extra upfront costs of construction and M/E/P installation will all be recovered from reduced errors like these.

Not a bad idea, but ...

[damn_registrars]

It may be that the solution is to simply hire more nurses and the like and to cut down on the overtime that lead to the mistake. Again, it will cost more on the front end for labor, but at least the lawsuits will decrease.

Many parts of the US (and I suspect other parts of the world as well) are facing significant nursing shortages. Even if you have the money to hire more nurses, they simply aren't there to be hired. This problem is then magnified by the fact that nurses make more money as nurses than as nursing educators, so nursing schools around the country are unable to expand their classes due to lack of qualified instructors.

Re:Not a bad idea, but ...

[fdrebin]

However that is not universally true (though I think it was more true a while back).

In the Denver area hospitals are frequently understaffed, but the hospitals refuse to hire many of the available nurses.

In particular the problem is that a significant percentage of new nurses can't get hired because there are policy (and regulatory? dunno) reasons that you can't have too high a percentage of staff being new graduates, due to their lack of experience. So new nursing school grads have a tough time getting hired around here.

My wife (a nurse) is involved in the training and orientation of new hires at her hospital, so she's relatively up on the issues. Also related is that there are some hospitals which are hurting financially due to the current general economic issues - a lot of that depends on the mix of patients and how they pay (insurance, if any, Medicare etc.)

There is also age discrimination for nurses in the opposite direction - my wife has been refused jobs because she's 'too old' or 'overqualified' etc. Not as bad as in the software world but it does exist.

Re:Not a bad idea, but ...

[frank_adrian314159]

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.

This is not a regulatory issue. It is entirely policy-driven. Why? Insurance rates go down based on the mean-time of experience at an institution. More inexperienced personnel = higher insurance rates.

God, I love our heath care system. It's so much better than anyone else's in the world - at least with respect to the number of people who are able to make money from it...

Why this is happening.

[Beorytis]

From TFA:

"Julie Thao, a nurse at St. Mary’s Hospital in Madison, Wis., mistakenly put a spinal anesthetic into a vein..." "Ms. Thao, who had worked two eight-hour shifts the day before, was charged with felony neglect. She pleaded no contest to two misdemeanor charges."

So the nurses themselves are taking the fall. In the eyes of the industry, "problem solved."

"...an abbreviated device-approval process that requires only that the manufacturer prove that a new product works just like an old one, whether the old one is safe or not..."

So ironically, a reform of the regulations to make new products safer than old one will also delay the approval and deployment of the new, safer products.

Simple solution

[brain1]

We, in the electronics industry, solved the problem decades ago by two simple solutions. Color coding and making connectors unique so you cant plug the wrong plug into the wrong connector. You might have to stock more tubing and catheters - but when human life is involved the argument falls flat.

And yet, with human life on the line, the medical industry cant seem to grasp such a simple concept. Very sad, and it makes me worry as I have a daughter that is expecting soon.

Already incompatible

[adoarns]

Reading about this, it occurred to me that there could be more safety in this area. I have worked in ICUs where the patient had two IVs, a central line, an arterial line, a lumbar drain, and an endotracheal tube: around the patient were crowded a mechanical ventilator, three IV poles equpped with IV pumps, a monitor, and a crash cart. The nurses were helped in this by, for instance, labeling each line with a small tag. Also, generally in ICUs nurses take care of two or three patients max for twelve hours at a time, meaning they can attain familiarity.

At the same time, it would take an awfully ingenious method to get most automated sphygmomanometer air lines hooked into an IV line. That's just completely stupid.

simples

[Anonymous Coward]

Make tubes different diameters for different jobs as dictated. Relax in bath of win.

It's not all downside.

[demonlapin]

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.

Re:It's not all downside.

[Krahar]

Make a 2 inch tube that everything can plug into on both ends to preserve versatility in an emergency. It's just that every doctor should know to pay extra attention when using such a thing. Use the safe connectors out of an emergency where 20 seconds spent hunting for a tube isn't a problem.

Why has no one taken this thread seriously...

[TrisexualPuppy]

...or bothered to examine the actual nature of the problem?

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.

Now there are plenty of circumstances where standardization is called for, and I am for it. Some nurses are overworked and have to work long shifts, and there are plenty of times when the medical staff have only minutes to save a patient. There is also the case that everyone makes mistakes at some points, even after a single check, double check, or triple check unless someone else is there for an extra set of eyes. Standardization would really help here, and I am for it. I, however, am NOT going to rely solely on the FDA to "protect" me from someone's mistakes. Those in the medical field are going to have to regulate themselves as much as possible because federal bureaucracies sure as heck aren't going to set regulations quickly enough for changing industries, and they SURE as heck aren't going to know every little problem that can occur.

Re:Why has no one taken this thread seriously...

[conspirator57]

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

about 0:40 into the trailer.

Re:Why has no one taken this thread seriously...

[Dragoness Eclectic]

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...

[TrisexualPuppy]

Why is it that in the engineering world, current still flows from positive to negative poles? Should be simple to get in there and change the convention, shouldn't it?

Re:Why has no one taken this thread seriously...

[darkrowan]

Oi, where's some mod points when I need them. The electronics world and our plugs was the first thing I thought of.

Re:Why has no one taken this thread seriously...

[TheCarp]

Or... the obvious one.... label the tubes!

Seriously... this problem doesn't need the FDA, it needs the guy who runs our data center who makes them label every single cable.

Or the manager from neteng who goes in to inspect a switch, and if the cables are messy, he grabs diagonal cutters, cuts all the ends off in place, and makes them recable the whole thing.... actually... that might not translate as well....

-Steve

Re:Why has no one taken this thread seriously...

[delinear]

Well said! If car manufacturers can fit an adaptor on a fuel pump to stop me filling up my diesel with unleaded when I fill up tired first thing, then it's ridiculous to claim the responsibility for tracing every damn pipe to origin in the middle of a life saving procedure when you've been run into the ground by an emplyer terminally short staffed putting constant pressure on you to work long hours, take extra shifts, work through the night because they're using what should be on-call emergency time to get the waiting list for routine operations down should rest entirely on a nurse. This is all about cutting costs and shifting all the responsibility onto the shoulders of people who are already overworked and underpaid (hey, we know you won't quit because you joined the caring industry for a reason, so we'll just dump crap on you until we need a scapegoat to fire when it all goes wrong). IANANBMGFI so I see first hand the ridiculous lengths they're expected to go to. They're often so tired that, were I in that state, I'd not feel happy writing competent code, never mind making life or death decisions. If standardising some tubes makes their life a little easier, the patients' a little safer, then why haven't we had this years ago!

Re:Why has no one taken this thread seriously...

[canadian_right]

I would prefer different connectors for different things, plus a standard colour coding.

Re:Why has no one taken this thread seriously...

[Aboroth]

You have no idea how bad it is in nursing. And I'm glad that your friends are in nice, cushy jobs that somehow maintained a certain standard. In many places all over the country, there are practically no nursing jobs available, but at the same time, there aren't enough nurses. How can that be? Well, there is either no money to pay them or nobody is willing to pay them. For the jobs that are available, they get filled easily by all of the older nurses delaying retirement or coming back from retirement because they need the money. As a result the job market is saturated with nurses with a lot of experience looking for work. Since employers know that they can get nurses with experience, they require at least a year of experience nursing minimum or they throw out the application. Very, very, very few nursing jobs are available to new grads. The ones that are available are typically reserved for someone because of connections. Then you have ads all over the place, and of course "conventional wisdom" telling people that there is a nursing shortage, and all they need is a nursing degree and they can get a job. Lies. All so that these nursing schools can make money.

So we have a situation with a glut of people with nursing degrees with no nursing experience, and nobody willing to give them nursing experience. At the same time we have an aging nurse population who will soon not be able to continue, and maybe even require nurses of their own. What a fucked up situation.

So imagine you are a nurse, and you know about this situation. You are stuck in a shitty unit in a shitty hospital, like in Detroit, and you are overworked and the family members of the patients are rude and yelling at you, you have over twice the "ethical" workload because there aren't enough nurses and you can't just not give people medical care after they are admitted or you will lose your job, and you rarely see the doctors and they disrespect you when you do see them. Everyone in the unit is asking why you are there because they job sucks so much. It is pretty fucking stressful. I think at that point if you make a mistake, of any magnitude, it is understandable.

Re:Why has no one taken this thread seriously...

[Aboroth]

Well I think something like "when tube is used for IV put red mark on ends" is probably a little more do-able than re-writing every textbook on electricity or going back in time and smacking Ben Franklin.

Re:Why has no one taken this thread seriously...

[TheCarp]

Actually, harder than you might think. One of my coworker tells the story of when our company sat down the heads of several major hospitals to discuss.... bed pans.

The reason: each hospital in the network buys its own bed pans, from different vendors. It was realized that they would actually save a million or two a year by just, agreeing to buy one standard bed pan from one company together.

These big shots sat around for a couple of hours, and left the room with no decision. In fact, still to this day, they purchase bed pans separately.

Instead of saving millions, they wasted several thousand dollars "worth" of these highly paid executives time, and called it a day.

-Steve

Re:Why has no one taken this thread seriously...

[Rob the Bold]

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. 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 again.

Everyone who designs anything that gets used by anyone should read The Design of Everyday Things 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...

[TheCarp]

I guess it all depends on where you want to solve the problem. An FDA mandate would take research and years and political fighting. Simple labeling can be implemented at the hospital level, with no FDA requirements. No years of waiting, it could be solved, today.

Then if the FDA solves it, all the better. In the mean time, maybe it saves a few lives.

-Steve

Re:Why has no one taken this thread seriously...

[wealthychef]

So here's the best of all possible worlds: hold the hospital management responsible for deaths in their hospitals due to this kind of mistake. Let them figure out how to prevent it, but just give them jail time if they don't. Or offer them $1million to solve the problem. X-prize for the first hospital to have zero accidental deaths in a year! This has the government doing what it does best, which is to punish, prevent, reward and break things, and private industry to do what it does best, which is look after its own greedy self interest.

Re:Why has no one taken this thread seriously...

[IMightB]

I don't agree with you. The computer industry doesn't agree with you. Ever look on the back of your computer and notice that everything is color coded and can only fit in the correct male/female plugs?

Re:Why has no one taken this thread seriously...

[Anonymous Coward]

I wonder if you could take that clip and label it "THIS IS WHAT OBAMACARE WILL BE" and get the sheep riled up.

Re:Why has no one taken this thread seriously...

[pspahn]

My girlfriend is a nurse, and a damn good one. Most of her friends are also nurses, so I have had plenty of opportunities to hang out with a bunch of nurses talking shop. In my observations, there are a lot... A LOT of substandard nurses out there simply because there is such a demand for them. I've heard plenty of stories about how bad they are to know that if/when I end up in a hospital, I sure as shit don't want some unknown nurse caring for me, I've met too many that are borderline imbeciles.

Unfortunately, this is not likely to change any time soon, as the Bureau of Labor continues to tout nursing professions as one with the most demand and future job growth. That along with a cushy salary and (despite what many think) fairly easy schedule and opportunity to travel, the quality of nursing is likely to stay where it is or else decline.

Re:Why has no one taken this thread seriously...

[pandaman9000]

This is exactly my thinking. the government protecting me from anything needs to be questioned. Despite idealistic notions, mistakes DO happen. The government cannot guarantee anything here. More regulation of stupid, trivial things takes away time and resources that could be spent on preventing serious issues. Like drug side effects, or the extremely long backlog of drugs needing approval to SAVE lives.

Lawsuits are put to good use in instances like these, where the manufacturers don't differentiate fittings or tubing. The FDA is unneeded.

Re:Why has no one taken this thread seriously...

[BJ_Covert_Action]

So far that I know of, having a "reverse convention" in all circuit diagrams everywhere hasn't gotten people killed yet. If you touch a circuit that is powerful enough to kill you, it won't matter what direction the current is flowing in vs. what direction it is labeled as flowing in on the diagram. Of course, feel free to point me to any sources/stories of a backwards convention in electronics directly resulting in a person's death.

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...

[toxonix]

Is it way too obvious a solution to use labeled tubes? Or do they normally just cut the tube from a big roll of universal clear medical tubing? Medical equipment is really expensive, so creating a standard and enforcing it is probably not cost effective or possible in the short term. Much of the equipment needs to function for many years. Of course, someone could label the tubes wrong...

Re:Why has no one taken this thread seriously...

[pandaman9000]

This is the better approach. No government needed. The industry itself makes a standards group, and self resolves.

People pushing for more government interference on matters like these are likely the same folks wanting to make the millions of illegal immigrants legal, and to further reduce border controls. What happens to already understaffed hospitals when their legitimate patient load goes up by 10% for more than just dire emergencies? BTW, the answer should be self-evident.

Re:Why has no one taken this thread seriously...

[necro81]

Apparently the medical devices industry hasn't heard of something like "industry standards".

The medical industry does have a standard: the tapered Luer fitting. The problem stems from the fact that they use it for everything.

Re:Why has no one taken this thread seriously...

[Anonymous Coward]

If you're connecting an air hose to an IV, there is something really wrong.

If you can connect an air hose to an IV even without muttering "I know I shouldn't be doing this, dammit!" three times, there is something really wrong.

Thank you for using our AC content-correction service!

Re:Why has no one taken this thread seriously...

[Nadaka]

I agree this is something that could be handled with a few rolls of color coded sticky tape, a dorky 15 minute training video and a reference card for each nurse.

Re:Why has no one taken this thread seriously...

[Crudely_Indecent]

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.

Re:Why has no one taken this thread seriously...

[budgenator]

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.

Re:Why has no one taken this thread seriously...

[TheCarp]

Well now you are putting words in my mouth. I am not saying the FDA shouldn't come up with a solution... just that, until they do, this isn't rocket science, the FDA doesn't NEED to solve it.... they can, and probably should... but in the mean time... is it that we care about peoples health? or do we care about compliance with regulations?

Because if we care about peoples health, we should solve the problem. If we care only about regulations and whether or not we can be sued... well... then wait for the FDA.

Admittedly, I know that the latter is more the speed at many institutions. We came down to the wire when it came to getting mobile devices encrypted, and likely wouldn't have done it at all if it wasn't for regulations like HIPA.

-Steve

Re:Why has no one taken this thread seriously...

[cosmicaug]

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.

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 helium tank. This is not because I'm a genius or because I never make mistakes but because the parts don't fit together.

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.

So you want to blame private industry, instead? Who gives a damn? Six of one, half a dozen of the other.

Seeing this as some sort of political statement is really not particularly productive. It is what it is and what it is is a problem with a trivial solution (design parts which are not supposed to ever be joined together so that they do not fit together) with no drawbacks and which has the potential to totally eliminate the grossest manifestation of the problem altogether.

The solution for this problem will, of course, not totally eliminate related problems of right tubes being connected together but having the wrong stuff or the wrong concentration of stuff (i.e. wrong IV drug in an IV line or too much or too little of the right drug). Such has to be dealt with by other means (changes in training, changes in working conditions, explicit checklists, etc.).

Re:Why has no one taken this thread seriously...

[budgenator]

I doubt this will work,
1, to label, the packages would have to be opened which contained the tubing that are frequently sterile and temperature sensitive;
2, doing this is probably considered manufacturing by the FDA requiring 501K registration
3, a 501K registered medical device manufacturing requires everything to be documented even how you mop the floor.
4, a medical device manufacturer has significant produce liability.

Re:Why has no one taken this thread seriously...

[wealthychef]

I didn't put words in your mouth. I posted my idea of a solution, which is for the FDA to mandate a result and a consequence/reward, without trying to specify how to achieve the result. This would clarify things on both ends. When the government specifies means to the ends it desires, it often gets the means wrong as it cannot know the best way to do things. Also, it loses the big picture and people get buried in paper work showing how they are complying with idiotic procedures that don't work. Government should specify desired outcomes, rewards and penalties, and avoid specifying how to achieve those results.

Re:Why has no one taken this thread seriously...

[uniquename72]

I think he meant apply the label at the time the tube is used. It already will be open at that point.

Re:Why has no one taken this thread seriously...

[nolife]

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.

I understand your position on this but realistically, people make mistakes. If the mistake is common, why not reduce the non human part of the problem. The air conditioning system in your car has a high pressure and a low pressure access port. They are standardized and two different sizes to prevent someone from attaching a refrigerant charging apparatus to the high side which could blow something up. Not only that but the old R12 A/C systems have two completely different sized ports than the newer R134A systems. That prevents someone from putting the wrong refrigerant in the system. Sure, anyone can follow the lines back to the compressor and see if they are working on the low or high side but the "human" fix of using different port sizes helps prevent mistakes.

Re:Why has no one taken this thread seriously...

[TheCarp]

Ahh ok, I read you very wrong then. Mea Culpa.

I actually agree completely then. I came to the same sorts of conclusions about government after reading articles on object inheritance. Or rather, implementation inheritance vs interface inheritance. It seems easy on the surface to implement a solution and then tell everyone to use it... but such approaches tend to suffer from being inflexible when dealing with real world uses.

Far better to tell everyone how to interface, and what information is required in both directions to ensure that things are working, and then let the people who have to interface with you implement their own solution.

So essentially, let the hospitals solve the problem, but have the FDA mandate that they solve it :) Sounds good to me.

-Steve

Re:Why has no one taken this thread seriously...

[Mashiki]

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.

What? Wait, what? You're seriously shitting me right? The average nurse around here works 11hr days, some double or triple shifts in a row because of cost-cutting measures. And yes they're fatigued, badly. There's a critical nurse shortage in many places in the world. That includes, the US.

Color coding would go along way to fixing a lot of simple issues. Even if it's simply tubes, but they'd have to hammer out the AB(blue), salts and salines(green) and things like that, and it'll still take 10 years for them to figure it out.

Re:Why has no one taken this thread seriously...

[Anonymous Coward]

Get with the recent times, it is HOLE flow that goes from + to -, not current flow.

Re:Why has no one taken this thread seriously...

[wealthychef]

OK, then we agree, and we need to form a new party, the Leaf Party, which insists on devolving implementation details to the leaves whenever possible. :-)

Re:Why has no one taken this thread seriously...

[TrisexualPuppy]

The conventions are not analogous as you are trying to make them, but they are indeed completely analogous. Consider the amount of work that it would take to change the electronics convention in education. 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.

Abstract:
1. You have a sucky method to begin with.
2. It takes a huge amount of time, energy, and money to change the sucky method.
3. In the long term, it is much preferable to fix said sucky method, but it is far easier and cheaper in the short and medium terms to remain here.

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.

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?

Re:Why has no one taken this thread seriously...

[GameboyRMH]

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...

[Andrewkov]

So nursing is just like every other profession then..

Re:Why has no one taken this thread seriously...

[TheCarp]

Of course... you know where this will die...
"Hello Staples"
"Yes I have a question about this model of label maker that you sell"
"Yup I know it, go ahead"
"Is it FDA approved?"
"Excuse me?"
"Is it FDA approved?"
"I don't see any information on that here, you may need to ask the company".
"Ok, well which of your label makers do you know is FDA approved"
"Approved for what?" ....

-Steve

Re:Why has no one taken this thread seriously...

[GameboyRMH]

I wonder if it would help if an organization like the ISO (not sure if there's a more fitting choice) came out with a set of standard color codes for medical tubing. Manufacturers would jump on it since it gives them a marketing advantage, and hospitals would pick them up since they're safer and shouldn't cost any more than the current tubing (even if they cost a bit more they should pay themselves off in a reduction of lawsuits from families of dead patients). Then when governments get around to legislating a fix they could just mandate the existing standard.

Re:Why has no one taken this thread seriously...

[Dalambertian]

Why is it that in the engineering world, current still flows from positive to negative poles? Should be simple to get in there and change the convention, shouldn't it?

Say the convention were flipped. Well, what happens when we start carrying current using holes instead of electrons ?

Re:Why has no one taken this thread seriously...

[TheCarp]

I much prefer putting a label on afterwards. Else, what do you do when you run out of one color tube and need a tube right now? You may have 100 tubes of the wrong color, do you not use a workable tube due to it being pre-colored? Can a color blind person be a nurse now? (does it matter what type?)

Then it still works when we are trying an experimental procedure and need a tube for something that they never came up with a color for. Also, I doubt color would be enough, what if I need seperate IVs for different reasons? Sometimes it comes down to not even an incompatibility within the patient but, two drugs can't be mixed in the tube because they react. (no examples off the top of my head, but I have heard of it happening)

Overall though, this isn't a bad solution, I could see it working.

-Steve

Re:Why has no one taken this thread seriously...

[budgenator]

Sure everybody knows you can't confuse the RJ45 connector on a cat3 cable to the telephone system with a RJ45 connector on a cat6 cable to the gigabit ethernet and the 100VAC ring signal isn't going to smoke-test your network card.

Re:Why has no one taken this thread seriously...

[demonlapin]

Don't be an LPN. Preferably, don't be an associate's degree RN. Get a BSN, it's more work but it'll get you hired and it will open the doors to administration when you get tired of actual nursing.

Re:Why has no one taken this thread seriously...

[Sparr0]

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...

[Coren22]

or maybe the cost cutting measures that are always happening everywhere else led to the development of a interchangeable tube design so those overworked nurses don't go to supply and grab an air hose only to realize they needed an IV tube? When the nurse goes into a drawer for a tube, it doesn't matter which one they grab, they all work. If the nurse is over worked and can't take the time to trace the tube, then the hospital is culpable for overworking their staff, they made the decision to cut staff, and this is the result.

Re:Why has no one taken this thread seriously...

[Gazzonyx]

Don't use green for tubes. Many people are color blind to green.

Re:Why has no one taken this thread seriously...

[Rich0]

Yup - people say that the problem with the medical field is that there is too much cost-cutting. The real problem is that there is not enough, and the wrong areas are cut.

Just ask anybody on /. who works in a hospital - doctors do whatever they feel like doing, and nobody can tell them otherwise. In any other industry they'd simply be fired.

Granted, executives running fiefdoms is nothing unique to the medical industry. What is unique in medicine is a lack of competitive pressure. Who shops around to get a good price on surgery?

Re:Why has no one taken this thread seriously...

[Rich0]

I think you hit the nail on the head. When people admit problems and fix them we punish them with lawsuits. When they deny a problem for ten years, they often get away with it (or at least they delay the payment for a decade - which is great from a time-value-of-money perspective).

We need to encourage companies to come forward and fix problems, not to bury them.

Re:Why has no one taken this thread seriously...

[Anonymous Coward]

>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...

[Anonymous Coward]

I think you missed the point of the word "ideally". Person A says nurses should never make this mistake, Person B responds, ideally no cause they're never tired, the point is is paint a picture that the ideal isn't real. hence saying "ideally nurses aren't working 12 or 14 hour shifts back to back" and not "ideally nurses only work 8hrs a day and everything is perfect!"

Re:Why has no one taken this thread seriously...

[wantedman]

I somewhat agree with the GP. While it's true LPN is somewhat of a worthless degree, a BSN is only a guaranteed job if you're willing to move. I volunteer at a hospital, and I can go all day without seeing a nurse under 40. In fact, 60 and 70 year-old nurses greatly outnumber 20 and 30 year olds, even though 20 and 30 year olds greatly outnumber 60 & 70 year olds in the population and let's face it. Health care is for the young, since it's a very strenuous activity with it's 12+ hour shifts and constant walking. With all the nurses being trained every year, and the huge waiting list at colleges, I can't help but wonder where 20 and 30 year olds end up. My guess is McDonald.

Re:Why has no one taken this thread seriously...

[kabloom]

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.

It's a situation that will correct itself quite easily -- as those aging nurses are unable to continue, the younger nurses will finally get some experience and be able to get jobs. And I'm not sure what this whole rant about aging nurses has to do with the real issue from the patient standpoint which is ...

There are practically no nursing jobs available, but at the same time, there aren't enough nurses [for the true necessity, though there are plenty of nurses to fill the available positions]. Well, there is either no money to pay them or nobody is willing to pay them.

Re:Why has no one taken this thread seriously...

[Anachragnome]

"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."

The Automotive industry has been color-coding wiring, and making the connectors so they ONLY fit the mate connector for decades.

My 50 year old Ranchero had both color-coded wiring and asymmetric connectors.

Maybe some people are not as smart as we think they are, or as smart as they think they are.

Color-code(transparent colorants!) the actual tubing, and use specific connectors for specific tasks (i.e. Red for IV, green for waste products, blue for oxygen, etc.). Solves the problem. It is an easy solution that I am sure MANY have already thought of.

Many medical devices are invented by the people that use them--Doctors. But, from my OWN experience, they rarely do so unless the idea is patentable. Color-coding and connectors are unlikely to be patentable. I hate to say it, but this is the most likely reason none of this is in use--it is unlikely to increase profits from an individual doctors standpoint. Hospitals, on the other hand, have every reason in the world to do this--it will DECREASE liability, and hopefully reduce operating costs as a result.

So, who do YOU think is in charge?

Re:Why has no one taken this thread seriously...

[Anonymous Coward]

"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. "

Colored tubes will not solve the problem because it is good to be able to see what is in the tube, and color matters. A better solution is unique connectors.

Re:Why has no one taken this thread seriously...

[Chris Burke]

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.

Re:Why has no one taken this thread seriously...

[HolyCrapSCOsux]

But next will be: Person dead after hospital ran out of tubes with red stripe : (AP) John Doe dies this morning when the hospital ran out of red stripe tubes. When asked why they didn't use a green one, they replied: "It's cheaper for the survivors to sue us than for us to be seen not following a government mandated color coding scheme."

Re:Why has no one taken this thread seriously...

[timeOday]

Any nurse who does something like this is purely incompetent.

You are barking up the wrong tree.

Here is a must read. Quote: 'You change the culture by giving people new tools that actually work. The old culture has tools, too, but they're foolish: "Be more careful," "Be more diligent," "Do a double-check," "Read all the medical literature." Those kinds of tools don't really work.'

Re:Why has no one taken this thread seriously...

[Chris Burke]

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...

[Chris Burke]

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...

[Yakasha]

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

Fine, you screw up, you go to jail.

The alternate is to tell your superiors you are overworked and cannot ethically continue to provide proper care to your patients.

They fire you.

You sue.

Policies change.

I think at that point if you make a mistake, of any magnitude, it is understandable.

So if somebody dies because of your mistake you just say "sorry" and its ok?

No. With some jobs you are not allowed to screw up. If you screw up, it is nobody's fault but your own. If you are in a situation that will make you screw up, you do the ethical thing and change the situation.

Re:Why has no one taken this thread seriously...

[demonlapin]

Well, FWIW, if you're going all day, that may be why you're only seeing older nurses. Try night. Many places, you have to work your way up to to get day shift.

You can always move to a less-desirable area. I'm in a small city (metro ~300k) in the southeast, in a university hospital setting, and we have plenty of nurses in their 20s and 30s.

Re:Why has no one taken this thread seriously...

[Aboroth]

Yes, refusing to work is the ethical thing, just like when you are starving in the street, it is the ethical thing to not steal that bread and instead starve to death. So what?

You are also assuming there is a standard ethical workload for nurses, defined in law somewhere. There isn't.

Sure, in fantasy land you can refuse to work, they can fire you, you can sue. And you would be in the right. But in the meantime, you need money to eat, and you need money to deal with a lawsuit. Where is this money supposed to come from, your ass?

In the real world, they fire you, and immediately replace you with someone who needs the money just as much as or even more than you. Not only that, but someone with years of experience, and who doesn't need much training, so there is little lost in getting rid of you. Plus if you want more than a settlement for "mental distress" or whatever, have fun figuring out what laws they are breaking. This isn't exactly the kind of thing the average overworked nurse has time to figure out, or would even know where to start.

Your black and white world is so nice and simple. I wish it existed somewhere beside your mind.

Re:Why has no one taken this thread seriously...

[Aboroth]

It is understandable that a human being will inevitably screw up something, eventually. Put them in a high stress environment like that, and you make it more likely. How on earth is that not "understandable"? I never said it was something we should ignore or was fine, it is just part of the human experience.

Screwups and mistakes are inevitable and inherently a part of nursing, when they are training new nurses. You just hope their supervisor catches anything that matters. Nursing school doesn't really prepare you for working in a hospital. New nurses screw up constantly and take a lot of resources to train. That is a big reason why hospitals really don't want new nurses. They are practically useless. (Yes, now go on a tirade and say that's not how it should be. Yes, that's nice, and we all know. Yawn.)

Since you are so high and mighty about this, how about you do the ethical thing and not just watch everyone suffer, and play armchair moralist, but go out and be an activist for proper treatment of nurses?

Also, I laughed so hard at your "screw up and go to jail" comment. Have fun getting nurses into the field when that policy goes into effect. You would get the nurses that don't need the job quitting just because they don't want to risk it, this increasing the workload for everyone else. You are an idiot.

Re:Why has no one taken this thread seriously...

[wombat1966]

I'm not in electronic OR medicine and it is the first thing that occurred to me. How hard could it possibly be to color code them? You wouldn't even need to replace all the existing tubes or connectors. Just put labels the ends. Pam http://www.nutrition--news.com/

Re:Why has no one taken this thread seriously...

[corellen]

I have to aggree with the above poster. Tubing is not all the same and neither are the connectors. All of my IV tubing is transparent and all of my BP cuff tubing is either black or opaque white and about twice the diameter of my IV tubing. I got out a IV cath and tried to hook it up to my BP machine. Now I was able to MAKE it fit but it was obviously not intened to fit and did not fit well. I did the same with a nasal canula/non rebreather mask and tried connecting them to an IV line, it is possible to make them connect but again it didn't fit well and was definatly not intended to. What I take away from this is a lesson in how badly fatigue can impare your judgment.

Re:Why has no one taken this thread seriously...

[thegarbz]

however, am NOT going to rely solely on the FDA to "protect" me from someone's mistakes.

No one's asking you too. However at the moment you have one single layer of protection between you and possible death. That single layer of protection has multiple modes of failures. Sure nurses should pay attention to what they are doing but human error is by far the weakest link. This is the foundation of every accident prevention mechanism. The best way is to eliminate the source of the accident (don't give people airhoses), where that isn't possible make it physically impossible to swap the two (use different sized airhoses, with different connectors), where that isn't possible use positive indication (a green air hose, a red IV drip etc), and where that isn't possible you relay on faith, faith that the nurse is well trained, isn't cutting corners, isn't skipping checks because the hospital is understaffed or because suddenly a big accident has overloaded the hospitals limited resources.

This human behaviour is the basic things we are taught to look for our whole lives. Pay attention to the people around you on the road because you never know when someone will change lanes without indicating, you never know if a pedestrian will j-walk. Pay attention when walking around because you never know if someone is asleep at the wheel and their car is coming right for you. Humans are imperfect beings, always have been, always will be. We're perfectly happy to blame the 15 deaths in the Texas City refinery disaster on the dangerous design of the blowdown stack and a faulty high limit switch, even though it could have been averted completely if operators didn't overfill the isostripper. Why should we be happy with relying on the nurses here when an engineering solution is so painfully easy to come up with.

Or put it another way. If the nurse didn't spend 2 min tracing all the identical coloured lines backwards and forwards while you're lying on your bed chocking you would get your airhose 2 minutes faster. There's not only opportunity for accidents to be avoided by taking the onus away from the nurses to get this right via a proper engineering solution, but there's also opportunities to improve efficiency and potentially save lives which weren't even lost before.

Re:Why has no one taken this thread seriously...

[RichiH]

Yes, you are right. They should take care.

Still, every single connector on a PC is designed in a way that you can't do any harm unless you truly intend to. Why should that not be the case for life-support measures?

This self-regulation which is supposed to change things that you speak of failed to achieve anything in the last few years for this specific problem. I am interested in why the failure of private industries to act makes them better for the job than the public sector, which failed in exactly the same way.

Re:Why has no one taken this thread seriously...

[RichiH]

First of all: Thanks. You seem to know what you are talking about and the info is useful.

Still, making it "hard" to connect two things that should not be connected is worse than making it "impossible unless using duct tape". Simply code them with notches or something. And create a _global_ standard before you run off doing things locally.

Re:Why has no one taken this thread seriously...

[cynyr]

Hmm how long has nursing been a profession? ohh right about as long as we have been around.

Simply that you don't have a regulatory body interested in making sure that things are different, and you have company A trying to lock company B out of their devices.

Re:Why has no one taken this thread seriously...

[Yakasha]

Yes, refusing to work is the ethical thing, just like when you are starving in the street, it is the ethical thing to not steal that bread and instead starve to death. So what?

Soup kitchen. Homeless shelter. Like a nurse choosing to tell their superiors that they are incapable of servicing that many patients safely, a starving person has other options.

You are also assuming there is a standard ethical workload for nurses, defined in law somewhere. There isn't.

No I'm not. I'm assuming you have the mental capacity to figure out when somebody is giving you too much work. I'm also assuming that the laws governing criminal negligence are still in effect. Ever hear of an overworked E.R. doctor giving a patient the wrong dosage, killing the patient, and then going to jail?.

Sure, in fantasy land you can refuse to work, they can fire you, you can sue. And you would be in the right. But in the meantime, you need money to eat, and you need money to deal with a lawsuit. Where is this money supposed to come from, your ass?

In cases like this, it doesn't matter. It doesn't matter for exactly the same reasons as when a CPA at KPMG is asked to cook the books for Enron. That CPA has a choice: do it, or get fired and starve. Guess what? The CPAs that cooked the books are in jail (or served their time or struck a deal.) You don't have the right to do something unethical just because the alternative is inconvenient.

In the real world, they fire you, and immediately replace you with someone who needs the money just as much as or even more than you. Not only that, but someone with years of experience, and who doesn't need much training, so there is little lost in getting rid of you.

Yup. Life isn't fair.

Plus if you want more than a settlement for "mental distress" or whatever, have fun figuring out what laws they are breaking. This isn't exactly the kind of thing the average overworked nurse has time to figure out, or would even know where to start.

Not true at all. Wrongful termination suits include violations of an established code of ethics. Health care workers do have a code of ethics that controls their ability to practice. That code I'm sure includes giving the best care possible, which would not be possible if you allowed your superiors to overwork you.

As to where to start, that is also simple: Talk to a lawyer.

Your black and white world is so nice and simple. I wish it existed somewhere beside your mind.

It does. It exists in the real world too. You should try it out.

Re:Why has no one taken this thread seriously...

[Yakasha]

Also, I laughed so hard at your "screw up and go to jail" comment. Have fun getting nurses into the field when that policy goes into effect. You would get the nurses that don't need the job quitting just because they don't want to risk it, this increasing the workload for everyone else. You are an idiot.

The policy is already in effect. It is called criminal negligence.

You are an idiot and an asshole.

I work as a nurse...

[Anonymous Coward]

In a 24 bed icu. I've read the official reports associated with many of the incidents listed in the summary.

The BP cuff was a family member forcing together two incompatible connectors in an attempt to be helpful.

Enteral feedings into venous catheters involved kluges on the part of the nurse (forcing a connection) or the doctor (using venous tubing for a non-venous site)

As an engineer (BSME) and a nurse, I say there is room for improvement. But the situation is not as dire as the summary claims.

Standards not FDA

[Anonymous Coward]

Bah. The FDA (government) cannot and will not "fix" anything. They'll come up with ridiculous and expensive "solutions" that won't actually solve the problem. The "correct" way to resolve this is to work appropriate AAMI and ANSI standards. Having such standards actually reduces vendor risk, increases vendor efficiency, and makes things safer. Easy button.

The real FDA...?

[Anonymous Coward]

The Attack Dog: The Role of The FDA Racketeering in Medicine - The Suppression of Alternatives

by James P. Carter, M.D., Dr. P.H.

"The thing that bugs me is that the people think the FDA is protecting them. It isn't. What the FDA is doing and what the public thinks it's doing are as different as night and day".- Dr. Herbert Ley, Former FDA Commissioner, 1970

The FDA was created at the beginning of the century by government, with input from the AMA, to govern the safety of foods, drugs and cosmetics. It had no legal power to test drugs for safety, however. The following account of the history of the FDA's role has been taken from a talk entitled "The Rise of the Cult of Pseudoscience," given by Dr. Charles Harris, a pathologist, to the American College of Advancement in Medicine a few years ago.

In 1927, the FDA became a separate agency required to test drugs for safety. In 1959, Senator Estes Kefauver (D-Tenn.) launched an investigation into the pharmaceutical industry which had already been accused of gouging the public. In the midst of the investigation, the thalidomide tragedy occurred. Some historians say this tragedy was significant in that it slowed the development of new drugs, because of the additional bureaucracy which resulted. (Actually, thalidomide remains a useful drug in the treatment of leprosy; it also stimulates the immune system. Instead of teaching doctors how to use thalidomide properly, as it did in the case of the new acne drug Acutane, the FDA prohibited the use of thalidomide altogether.) Also during this time, unethical medical research was uncovered in New York City. Cancer cells were being inoculated into nursing home patients to determine what would happen to them, unbeknownst to the patients or their relatives.

These events caused opposition to human experimentation, which became severely regulated. A stronger FDA emerged, which was required to guarantee not only safety, but effectiveness as well. This meant that human subjects had to be involved in order to accomplish this. Otherwise, proof of efficacy would be impossible. The pharmaceutical companies then began to offer medicines and monies to the universities to conduct the necessary clinical trials to show efficacy. The academics began to worship at the altar of clinical trials. The result, tragically, was that the double-blind crossover study became the "double-cross blindover study". . .the real cult of Pseudo-science was born.

The new rules and regulations pushed by the FDA resulted in these disadvantages:

Slower development and delivery of new drugs An intimidated pharmaceutical industry (until they began to win friends and influence people) Medical services that had been offered voluntarily in connection with clinical trials now made mandatory, either executed or enforced by the FDA Refusal to look at alternatives Sluggish response times; lost new drug applications; bribery; indifference; promotion of generics leading to a generic drug scandal, and a total lack of flexibility THE AMA CAUGHT RED-HANDED COLLUDING WITH THE FDA

The government-sponsored chelation studies (covered in an earlier chapter) at Walter Reed and Madigan Army Hospitals did not originate from any burning desire for scientific inquiry on the part of the FDA, academia or pharmaceutical corporations. What, then, motivated them to help design and approve a controlled study to evaluate the safety, effectiveness, and dose-response curve of EDTA in the treatment of peripheral vascular disease?

The answer lies in the comments of Stuart Nightingale, Asst. Commissioner for Health Affairs of the FDA, when he went on record at a meeting of the House of Delegates of the AMA in Honolulu, Hawaii, seven or eight years ago, telling AMA delegates, "We can't put these chelation doctors out of business by ourselves. We have to work closely with you, the AMA, and other groups, to put them out of business."

It happened that a leading chelation doctor, Garry Gordon, was in the audience intending

They need an independent commission

[rcamans]

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.

Now we know...

[Anonymous Coward]

...how Edward Murphy died.

Checklists. . .

[JSBiff]

Funny you mention checklists in medicine. There's other people, in the medical field, who've made the exact same observation you have. I remember hearing an interview back in January, on NPR, with Doctor Atul Gawande who is trying to encourage the use of standardized medical checklists in hospitals in the U.S. He wrote a book called, _The_Checklist_Manifesto_.

Change takes time, but given the results that guy saw, this is probably going to become standard practice in hospitals and clinics across the U.S. and probably the world. This really needs to happen. Like you say, checklists work to help manage memory and complexity in time-critical situations where the work *must* be done right. I think people resist checklists, because it makes them feel like they've become some sort of cog in a machine, but I for one recognize the limits of my memory and ability to manage complexity in critical situations.

Re:Checklists. . .

[couchslug]

"I think people resist checklists, because it makes them feel like they've become some sort of cog in a machine, but I for one recognize the limits of my memory and ability to manage complexity in critical situations."

Good point. When you teach people that checklist DISCIPLINE HELPS THEM do the job right, they are more likely to accept it.

Examples help. If checklists are good enough for the Blue Angels and the Thunderbirds, they are worth considering elsewhere.

Interns?

[wfstanle]

30 hour shifts for interns are legendary! When will the medical industry realize that this is a very bad idea.

Not what I've seen at all

[Anonymous Coward]

When my wife was ill (3 years of constant hospitalization) not once did it ever look like this was even remotely possible. All of the IV tubes were labeled, many of them were different (blood pressure cuff pump to an IV? I call BS on that) and they were never changing more than one at a time. Deaths related to these kinds of mixups are not the fault of IV lines "looking the same". Seriously, fix the million other problems, then think about IV lines.

Umm, Murphy's Law

[Anonymous Coward]

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?

http://en.wikipedia.org/wiki/Murphy's_law

Put simply, no matter how well trained the people are, and no matter how severe the consequences for screwing up are, a nonzero percentage of people will screw up a nonzero percentage of the time.

The only way to defeat it is to make screwing up physically impossible.

Solved in Gas Chemical Industry

[jonathansdt]

The major gas providers agreed to standardize on different connectors for different types of liquefied gas (hydrogen, oxygen, nitrogen, etc) long ago.

Yet occasionally you still get a guy who manages to connect things that can't be and BOOM.

What about McGeyver

[Aboroth]

I can see how all tubing being the same could be useful. In an ideal world you would have enough tubing of each type all of the time, but what do you do if all of the IV tubing is used up, and you badly need some, but you have a huge pile of other kinds lying there. Well if each kind has its own connector then you (well, the patient) is screwed. Sure you could have adapters, but then you would have to keep stock of adapters as well, and hope that if you run into that situation that there are adapters left. Not to mention that it adds another link in the chain that can go wrong.

Not that it is better than the alternative I just think everything should be considered.

Tubing connections with RFID

[chmodman]

They do make medical tubing connections with RFID. This allows the equipment to verify a proper connection before delivering anything through it. Also allows traceability of old connections, logging connect/disconnect, etc. http://www.pddnet.com/editorial-jim-brown-colder-products-trouble_free-fluid-connectors-for-medical-devices-052410/ This is mostly a cost issue, as old hardware needs to be replaced / retrofitted.

Who is the next goat ?

[rrey]

"Nurses should not have to work in an environment where it is even possible to make that kind of mistake,' says Nancy Pratt"

And once the nurse won't be able to do the mistake, who will be responsible of the accident ? The tube manufacturer ?
If the process in place to avoid the "nurse error" fails, is he person who put the process in place is responsible ??

Raise the nurse salary and make them work under 80 hours a week, maybe they'll be less accident like this.

Oblig Simpsons

[Vexor]

Nurse my catheter is full and my IV is empty.

*switch switch*

All better.

Color codes

[mangu]

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

If the patient is in a crisis there's no time to take extra care.

In industry tanks and tubing are color coded. Oxygen, for instance, is green. When pressurized oxygen comes in contact with grease it explodes spontaneously, so all threaded fittings in oxygen tubing must be scrupulously clean. No one will lubricate the threads if the tube is green.

Hospitals should do likewise, have a color stripe running the length of each hose, making it clear where it should be connected.

Re:Color codes

[Shotgun]

Not only that, on my welding tanks there is no way to connect my acetylene hose to the oxygen tank. The threads are reversed between the two. Having oxygen and liquid IV hoses using the same type of connector, in the same size of clear tube is just plain STUPID. You can't plug an ethernet cable into your telephone port. And your telephone won't take a fiber or USB cable. Hell, you have multiple type of fiber connectors just to distinguish the various types of cable. Nurses are called upon to constantly change connections around. Much more than any IT admin would ever consider doing. The current system is just begging for mistakes to happen.

Government workers...

[Anonymous Coward]

are self-serving gimps, only interested in preserving their money-sucking jobs and expanding a job-securing buffer of like-minded gimps around them.

You're really most sincerely wrong

[nbauman]

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

Re:You're really most sincerely wrong

[demonlapin]

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.

The Anesthesia Patient Safety Foundation has nothing whatsoever to do with government. Never did. You do need there to be an outside body that keeps looking for the big picture, and maybe the FDA is the right place to do that - but maybe it's not. The FDA, after all, has too much incentive as a regulator to be overly cautious - witness the story of sugammadex, which would have basically retired succinylcholine and neostigmine from clinical practice. In expressing concern over potential hypersensitivity, the FDA completely neglected the possibility that the status quo might be more dangerous.

Re:You're really most sincerely wrong

[nbauman]

Anesthesiologists had the same problem...

This shows that government can work.

The Anesthesia Patient Safety Foundation has nothing whatsoever to do with government. Never did.

I didn't express myself accurately enough. The anesthesiologists successfully used the model of safety engineering from the aircraft industry, which was managed and developed largely by the government (with civilian input).

I think you'll agree with my main point, that "personal responsibility" isn't the solution to hospital safety. Instead, it takes a systems approach. I think you'll also agree that, if you can solve a problem by telling people to follow a rule, or solve it with an engineered solution that makes it impossible for people to do it wrong, the engineered solution is better.

I don't know enough about sugammadex (or anesthesiology) to comment. I'll keep my eye out for it, though.

Yes, this is what I was thinking of. I remember that WSJ story too.

http://www.apsf.org/about_history.php

A seminal publication from Harvard in 1978 described the use of the aviation-inspired critical incident analysis technique to understand the causes of anesthesia-related mishaps and injuries. In the early 1980's, national media publicity turned a harsh spotlight on anesthesia accidents that injured patients. Thus stimulated, and avoiding the urge to fixate on tort reform, E. C. Pierce, Jr., MD, the 1984 President of the American Society of Anesthesiologists (ASA) constituted a new ASA standing committee on Safety and Risk Management, emphasizing the need to address the causes of patient injury. That same year, Pierce and Harvard colleagues convened the International Symposium on the Prevention of Anesthesia Mortality and Morbidity, which constituted the first organized examination of what was soon to be known as "anesthesia patient safety." There the idea for the APSF was born....

Overall, the combined impact of all the initiatives has been a 10 to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anesthetics...

Re:You're really most sincerely wrong

[Anonymous Coward]

I'm sorry but this is your arrogance speaking. I work in an ER and I see these issues everyday. The hospital I work at is a "State" hospital and the upper administration/government/federal government overseers are generally assholes with very little real world experience. Their input increases the danger for the patients 50% of the time. We are not "all in this together", we are a collection of individuals. Get a fucking job.

Re:You're really most sincerely wrong

[demonlapin]

I agree that "personal responsibility", while an important value in real life, isn't the way to structure a complicated system. I just wanted to make a point that the government - because of its role as regulator - will tend to be too cautious in approving potentially dangerous new methods while ignoring the risks of existing methods. I'll give you the short version of sugammadex:

When performing most surgeries - abdominal procedures, most broken bones, lots of ear/nose/throat procedures - the standard procedure is to place a breathing tube through the vocal cords; i.e., past the last possible obstruction. This guarantees a clear path to the lungs regardless of how the patient is positioned. To do this, we both induce anesthesia (give an agent to make someone unconscious) and, in nearly all cases, give a paralytic drug to make the process easier and less traumatic to the patient's mouth. There are two main choices: succinylcholine and rocuronium. Rocuronium is basically free of side effects, but once you give it, it will be at least half an hour before the paralysis can be reversed - and the reversal agent is neostigmine, which pharmacologically antagonizes the paralytic agent but contributes to nausea and vomiting. Succinylcholine (suxamethonium in the UK) chemically consists of two acetylcholine molecules joined back to back, and so it is metabolized by acetylcholinesterase (though somewhat slower than the natural ligand). It works by stimulating the receptors until they fatigue. Its great advantage is that it is very quick to act, and that it wears off after (usually) five to ten minutes. The downsides are that it can act as a trigger for malignant hyperthermia, that it reliably produces an increase in serum potassium (which could trigger ventricular fibrillation), and that some people have altered metabolism producing hours or even days of paralysis from a single dose.

In comes sugammadex, a large molecule that chemically binds to rocuronium and related molecules in the bloodstream and prevents them from paralyzing muscles. It means that we can give rocuronium, allow it to paralyze a patient, and quickly and safely produce a complete reversal if we aren't able to intubate the patient, without waiting for the drug to be metabolized. We can leave patients deeply paralyzed until the end of a procedure, making the surgeon's job easier (in open abdominal surgery, for example, the paralysis is necessary to be able to close the abdominal wall) while still being able to reverse the paralysis almost instantly. And we don't have to worry about the possibility that the patient will metabolize the drug too slowly.

The FDA's concern was about allergic reactions. This is a classic problem of bureaucracies; there is much less danger in saying no than in saying yes, just as nobody ever got fired for buying IBM. But by saying no rather than yes, they are ignoring the real danger that the current succinylcholine-vs-rocuronium choice poses to patients - one that is much less easily handled than an allergic reaction (or even frank anaphylaxis - it's not as though the drug would be self-administered in remote settings; it's made to be given in an OR or ER to a patient whose blood pressure, respiratory rate, oxygen saturation, pulse rate, and EKG are all being monitored). So we should be cautious about having the government do things, because it's inherently less flexible than private organizations (The Joint Commission being one example) that can easily serve most of the same role. Let the government regulate things that really must be regulated, but be careful what you loose them upon, because they rarely stop where you want them to.

Re:You're really most sincerely wrong

[nbauman]

Interesting. I once intubated a simulation dummy. You wouldn't want to be that dummy. I didn't know any of this about reversing paralysis.

I can understand why an anesthesiologist would want to add a drug like sugammadex in his armamentum. The problem of weighing costs and benefits when they involve rare, serious risks is damned difficult.

My easy answer is that you create an expert panel, let them review the evidence and hold hearings, and have them decide. If the FDA followed the advice of its expert panels (as I think it should), you should get the same kinds of conclusions with the FDA panels as you would with the professional societies -- or at least the same differences of opinion. (The European regulatory agencies approved sugammadex, didn't they?)

I'm very interested in this question of whether government agencies can make decisions and manage things better than private organizations, professional societies, and businesses.

Most of the time the discussion gets shouted down by people who have a belief based on their political ideology. I'm more interested in seeing the facts. There are social scientists who study this, but I've never systematically looked up their work.

I think a well-managed government regulatory agency could do a good job, if they used a valid process to appoint people to their expert panels, insulated them from politics, and followed their decisions. I used to think that you could quantify all the significant factors and put them into a big decision matrix -- would you have more deaths with or without sugammadex? But sometimes it gets more complicated than that.

Take a clue from SCUBA

[pushf popf]

In SCUBA diving, it's simply not possible to connect the wrong hose to the wrong thing.

Low pressure hoses (140PSI) simply do not fit in (3000PSI) ports. 200Bar regulators do not fit on 300 bar valves.

In fact, this is exactly the reason that household natural gas flexible connector fittings are no longer compatible with plumbing fittings.

There's absolutely no excuse for anything that connects to a human to have the possibility of a fatal mistake.

Give the nurse a sharpie

[bugs2squash]

And modify the connector to have a small writing surface on each part. The nurse can then make random sharpie strokes across the join and later match them up or otherwise label them in any ad-hoc manner that works for that nurse.

It comes down to people

[QA]

At the age of 8 my daughter went for dental surgery. We decided to have the procedure performed in the hospital rather than the dental office for safety sake. What could go wrong? To make a long sad story short, she died for 6 to 9 minutes. Nobody is quite sure because....NONE OF THE MONITORS WERE TURNED ON. The only person in the OR was the dental surgeon and he noticed her fingernails turning blue. She was long dead by this point.

As it turns out, the anesthesiologist had mistakenly given her a triple dose of morphine which in turn stopped her heart. Too bad they were all having a coffee prior to turning on the monitors. It was "only" dental surgery after all.

To thier credit (?) they brought her back to life. Around 90% of her brain was dead by that time. She had some stem function but even that was spotty as her body could not control temperature, etc. Stage one coma for a year, vent, etc. So after a year of being told there was no hope we made the DNR decision and pulled the tube. We were taken to a nice atrium (death room) with doctors and clergy present. They pulled the vent, 45 seconds later she gasped for breath and everyone about fell over. They hustled us out so fast it would make your head spin.
Many years and over a million dollars of therapy later, she can function. Had to relearn everthing and I mean EVERYTHING. She will always have a mental age of 12yrs (16 now) very bad motor skills (never drive) blind in left eye (optics fine, neural pathway not fine) and if you saw her on the street you would think she was "retarded". How I hate that fucking word.

So all the fancy procedures, fancy equipment, etc dont mean sweet fuck all if a HUMAN doesnt turn them on.

To finish, yes of course there was a settlement...thats going to give her life back right? Money means fuck all.

Devil's advocate

[ThatsNotPudding]

I'm sure coloring tubing has been thought of - along with the unitended consequences. Colorizing the tubing material might lead to toxic leaching or other interactions with what is passing through the tubing or induce allergic reactions, along with some colorants possbily not able to stably survive multiple sterilizations. Just coloring the outside of the tubing might even be worse from a wear / tear / transference point of view. Plus is color blindness more or less likely when dealing with transparent pastel colors? Different connector systems for different functions might be worth a look too, but I can only imagine the inventory nightmare and would incompatible connectors save more lives or cause more deaths in absolute panic, code blue situations?

Re:Devil's advocate

[KDR_11k]

Just stick a label on the outside of the exposed end that the nurse can look at to see what this tube is for?

Yeah, right.

[PPH]

From TFA:

"The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death."

I was there when the FAA came in to Boeing following a fatal accident and found the possibility of cross-connecting things like the engine fire switches. Although they did fix things, management continued to mutter under their breath about the costs. Keyed connectors meant additional inventory costs. Extensive functional tests following assembly meant additional labor. There was the feeling that, once the inspectors left the property, things were going to be put back the way they were.

Industry always pushes to minimize costs. And unless they are repeatedly inspected by independent regulators, they'll get their way.

Tubing adapters

[OrangeTide]

Adapters sounds like a lawsuit waiting to happen. It was impossible to hook up an oxygen supply to an IV line, until Killco marketed an adapter to do so.

If you're McGeyver you'll just cut the tubing with your swiss army knife and splice it together with some slightly larger tubing and some candle wax.

Orrrrr.....

[Anonymous Coward]

....how about people pay attention and VERIFY what they are doing before they do it?

reality check...

[Kane3162]

"""but because the agency is so worried about making industry happy""" if you haven't noticed, GREED, aka MONEY is the key to EVERYTHING that happens these days, I wait for the ACTA, and the MPAA/RIAA requests to pass and become law of some sort (the RIAA's recent request to have ISP's and more do filtering/monitoring)... I am not religious, but if their is a "god", then please let 2012 or sometime in my lifetime be the END of the world... or the greed of humanity (i know its a monster that has to be completely killed or it will regrow)... either way I have lost faith in humanity. reading the news online, walking down the street, watching the news on tv, and of course, having someone attempt to car jack me in the front of a walmart parking lot (literally 1 car length from the door) with 5 cameras recording the incident (truck was running, I got away with only a severely sore face), yeah... I cannot wait till the end.. However if you somehow see greed not being our future, and humanity stopping the current path they have been on since the dawn of the human age, feel free to disagree, otherwise, step aside or prepare for them to find something to sue you for and put you in permanent debt, or die because you lack funds (this accomplishes several things, modern day slavery and population control, while at the same time, making the rich richer...

I am a safety engineer...

[sean.peters]

... and I can tell you that this approach - blaming the operator for mistakes - doesn't fly. Sure, nurses shouldn't make mistakes. But they do. Systems should be designed to make mistakes less likely. That's what we do in defense systems, it's what we do in aircraft control systems, and it should be what we do in medical systems.

For the literary:

[smchris]

Catch-22? Johnny got his gun? Or both? I know it seemed like pushing the theme of insanity a little too far to me at the time. But, subsequently, I worked in a hospital in my 20s, and, well....
   

Shenanigans

[Anonymous Coward]

I call Shenanigans on this story. Having said that I work in Australia, but the tubing cant be that different. The only way you could could a naso gastric feed to an IV line is with duct tape, and we don't use duct tape. The only way you could connect a sphygmo tube to an IV is with duct tape, and as I said, we don't use duct tape. Either that or there is a level of incompetence that is astounding. I work in ICU and it is not uncommon to have 20 lines going into a patient. (not including BP and NG tubes, which don't really count) and part of the routine at the start of the shift is to sort all of those out. It can take over an hour sometimes. I can't comprehend how someone would connect an NG tube to an IV line accidentally, apart from it being a incredibly stupid.

If is a far bigger issue having illegible writing on drug charts. Some of the Doctors writing is less than a squiggle and it is meant to be an order for a drug. We had a doctor with notoriously bad handwriting writing up a chart once and I told him I loved his drug charts and he asked me why. Looking at the lines of completely illegible writing I said that at 3 in the morning when the s**t hit the fan and I need to give something, I looked at his drug chart, found exactly what I wanted to give, gave it and signed for it. He thought it was amusing, but the sad part is you could make out just about any drug name you wanted from his charts.
 

amen

[sean.peters]

You wouldn't think that if your son was one of the hundreds of deaths.

This is especially true given that it would barely cost anything to fix the problem. You'd have a small initial outlay to design new connectors, some expense to toss and replace existing ones (or not, you could conceivably phase this in as old systems wore out), and then... basically nothing, as it's hard to imagine the tubes would cost much more on an ongoing basis. You'd be saving some lives basically for free.

O rly

[sean.peters]

Speaking as a physician, it's your responsibility to know exactly what you're doing.

Speaking as a safety engineer, you don't know what you're talking about. The object of the game isn't to identify who's to blame after a mishap - it's to prevent mishaps from happening. And the fact is that nurses, like other human beings, are going to make mistakes. Period. The job of the system designer is to anticipate the mistakes that humans are likely to make, and design to system to make those mistakes easier to avoid. This is not a problem that can or should be addressed by macho posturing and/or finger pointing after the fact.

Not just an issue of mixed up tubing

[Anonymous Coward]

I was about to sit for my last session of dialysis before a kidney transplant. When setting up for dialysis, nurses are supposed to prime the return tube with saline, so as to prevent an embolism. The nurse has forgotten to prime the tube, and is about to make the final connection when I notice the problem. I mention it to her and she just laughs it off - "Oh silly me, chuckle, chuckle, chuckle" - and does the priming. She just about kills me and laughs it off, way too easily. This wasn't an issue with tubes getting mixed up. There are two much bigger problems: 1) Some nurses are dumb. Period. There are dumb people in every profession, and health care is no exception. 2) Smart nurses that have to work 10 or 12 hour shifts will be tired and unfocused towards the end of their shifts. An 8 hour shift is really the max you want for the kind of work that they do, and the kind of responsibility they have.

Must I solve everything??

[elfman345]

Get with the program, the solution is right in front of your faces. Simply color code the tubes available for purpose. For instance red lines for blood, yellow lines for air and green lines for food. Color coding is used exstensively in hospital settings already for a wide variety of uses and this would mean that it would be far more difficult to mistake tubes. The stripes should be along the tubes, like straws for beverages, and should not make the tubes opaque but help the nurses differentiate purpose. And these new tubes would not need a major revamp of the manufacturing process either as the stripes could be added on the outside and not change the major properties of the tubing.