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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.
We should have the tubes manufactured by the same companies that produce battery chargers for mobile phones. Problem solved!
My first program:
Hell Segmentation fault
And surely different color tubes (and/or sizes/connectors) would make industry happy. More sales of medical tubing if you can't interchange them.
"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 !
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.
Sounds like they're in need of a Poka-Yoke project.
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.
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.
This one's tricky. You have to use imaginary numbers, like eleventeen... --Hobbes
From the excerpt above:
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...
Ken
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.
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.
Consciousness is an illusion caused by an excess of self consciousness.
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.
This one's tricky. You have to use imaginary numbers, like eleventeen... --Hobbes
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.
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.
Obliteracy: Words with explosions
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.
No folly is more costly than the folly of intolerant idealism. - Winston Churchill
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.
Wanna fight ? Bend over, stick your head up your ass, and fight for air.
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.
A successful API design takes a mixture of software design and pedagogy.
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.
You are welcome on my lawn.
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.
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.
What ? Me, worry ?
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.
Blasphemy is a human right. Blasphemophobia kills.
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.
Blasphemy is a human right. Blasphemophobia kills.
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.
Blasphemy is a human right. Blasphemophobia kills.
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.
A successful API design takes a mixture of software design and pedagogy.
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).
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.
Intellectual Property is a monopolistic, selfish, and defective concept. It is "tyranny over the mind of man"
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.
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..
which is totally what she said
...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.
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?
"Trolls they were, but filled with the evil will of their master: a fell race..." -- J.R.R. Tolkien on Olog-hai
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.
"Trolls they were, but filled with the evil will of their master: a fell race..." -- J.R.R. Tolkien on Olog-hai
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.
wake up and hold your nose
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.
I had a dream, bright and carefree, but now there's doubt and gravity
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.
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.
The Tao of math: The numbers you can count are not the real numbers.
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.
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.
"Trolls they were, but filled with the evil will of their master: a fell race..." -- J.R.R. Tolkien on Olog-hai
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.
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.
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