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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.
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?
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..."
Ken
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).
God invented whiskey so the Irish would not rule the world.
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.
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.
It's a symptom of being overweight, not doing enough sports, and having way too much cholesterol in your bloodstream.