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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.
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.