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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.
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.
If Slashdot were chemistry it would look like this:Cadaverine
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.
>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.