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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.
..that's just a series of tubes, then
Donte Alistair Anderson Roberts - hi son!
Karma: Chameleon
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
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..
which is totally what she said
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.
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.
"There is a way that seems right to a man, but its end is the way of death." Proverbs 16:25 (NKJV)
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.
which is totally what she said
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.
"She's a scientist and a lesbian. She's not going to let it slide." Orphan Black
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.
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.
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.
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
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
It's called Poka-yoke from the Lean manufacturing world: http://en.wikipedia.org/wiki/Poka-yoke
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.
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.
- These characters were randomly selected.
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
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.
A successful API design takes a mixture of software design and pedagogy.
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.
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?
I am a free slashdotter. I will not be modded, blogged, DRM'd, patented, podcasted or RFID'd. My life is my own.
Hmmm I wonder if this Dr. Robert Smith fellow has... The Cure... to such problems...?
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.
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.
http://michaelsmith.id.au
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.
"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?
And did you exchange a walk on part in the war for a lead role in a cage? - Pink Floyd.
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 ?
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.
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.
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.
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.
http://michaelsmith.id.au
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.
Nae king! Nae laird! Nae yurrupiean pressedent! We willna be fooled again!
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...
Ken
'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.
Ceci n'est pas une signature.
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.
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.
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...
Ken
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.
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.
Seven puppies were harmed during the making of this post.
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
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.
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.
// MD_Update(&m,buf,j);
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.
>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.
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?
Free Martian Whores!
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.
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.
which is totally what she said
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.
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.
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.
But the connectors should be incompatible regardless of the hours and stress nurses are subjected to.
Many airport related problems are due to the conflicting mission of the FAA as regulator and promoter of aviation.
And a silver band means 10 percent tolerance, and gold means 5!
Shouldn't the free market have already addressed this problem?
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.
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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.
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?
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.
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.
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?
If I had mod points...
-- Lattyware (www.lattyware.co.uk)
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.
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.
You can't legislate goodness. Let each to his own destiny, by will of his freely made choices.
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.
If libertarians are so opposed to effective government, why don't they all move to Somalia?
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.
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.
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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.
"Educate the mind but never at the expense of the soul."~Blessed Basil Moreau
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.
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).
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!
"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...
Fungicide worked for me.
**TODO** Steal someone elses sig.
I'm okay with the idea of different connections, just as long as we don't let Sony anywhere near the scheme.
If libertarians are so opposed to effective government, why don't they all move to Somalia?
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)
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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.
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.
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.
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.
09 F9 11 02 9D 74 E3 5B D8 41 56 C5 63 56 88 C0
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.
"Educate the mind but never at the expense of the soul."~Blessed Basil Moreau
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...
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.
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"
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?
Troll is not a replacement for I disagree.
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.
Agreed, I've never seen a tube on a blood pressure pump that looks anything like an intravenous tube...
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.
Dan
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.
This one's tricky. You have to use imaginary numbers, like eleventeen... --Hobbes
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.
Troll is not a replacement for I disagree.
as a quintessentially Republican screed, then you're either: a) not paying a lick of attention, b) dishonest, or c) a Republican.
Oh. Wait.
No folly is more costly than the folly of intolerant idealism. - Winston Churchill
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.
Damn_registrars has no butt-hole. Damn_registrars has no use for a butt-hole.
So the nurses themselves are taking the fall. In the eyes of the industry, "problem solved."
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.
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.
You can't legislate goodness. Let each to his own destiny, by will of his freely made choices.
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.
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.
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?
Help! I'm a slashdot refugee.
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.
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.
-1, Too Many Layers Of Abstraction
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.
Tenemus pyrobolos atqui jacimus cognitiones.
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
but an insider with an outside line can
blog.sam.liddicott.com
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.
Mexico: 100% conservative's America now!
Don't defibrillators work?
Or does cardiac arrest count as a symptom?
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.
Why is it so hard to only have politicians for a few years, then have them go away?
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.
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.
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...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.
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?
I will bend like a reed in the wind.
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?
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.
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?
Why is it so hard to only have politicians for a few years, then have them go away?
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
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.
which is totally what she said
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..."
I've met girls with that kind of attitude to something potentially risky - "Just be careful".
Most of those girls are now mothers.
Sure, because there are humans who never make mistakes, especially under stress ...
The Tao of math: The numbers you can count are not the real numbers.
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.
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.
See my blog http://ilovecookes.blogspot.com/ for light hearted technical information.
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.
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...
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
Yellow for evacuation...
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.
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.
Wow, sent an e-mail as suggested when clicking on "use classic" banner, and got a fast response that addressed my msg
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!
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.
Insecticide worked for me.
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.
... but then, this cured only the symptom of having slept with the wrong person...
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.
The confidence of ignorance will always overcome the indecision of knowledge.
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)
Out of modpoints but really liked a post? 1BDkF6TtmmeZ3yqXbz9yhdYVqRYnwFoXDj
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.
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.
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.
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.
Reading comprehension fail #2. You're assuming that I meant that A, B and C were disjoint. Actually they're almost completely overlapping.
No folly is more costly than the folly of intolerant idealism. - Winston Churchill
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.
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.
which is totally what she said
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.
You're special forces then? That's great! I just love your olympics!
30 hour shifts for interns are legendary! When will the medical industry realize that this is a very bad idea.
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.
I suspect the answer to your question involves lots of focus group sessions, draft specifications, and requests for comment.
If libertarians are so opposed to effective government, why don't they all move to Somalia?
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.
---dragoness
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.
The Tao of math: The numbers you can count are not the real numbers.
Have a good^H^H^H^H long life.
Why is it so hard to only have politicians for a few years, then have them go away?
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.
Yet occasionally you still get a guy who manages to connect things that can't be and BOOM.
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.
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.
Anarchists never rule
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.
Anarchists never rule
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.
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.
I am not a crackpot.
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.
I am not a crackpot.
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.
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.
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.
"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.
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).
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.
I am not a crackpot.
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.
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.
*switch switch*
All better.
~Vexed and loving it!
If you're reopening sternotomies at the bedside, sterility is the least of your problems.
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.
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.
Go ahead and force them to use different tubes.
I'll make a fortune selling adapters!
BAM!!! good post!
This system is virtually idiot proof.
I have a few friends and a Youtube-ready video camera that would like to challenge that assertion....
Motorcycles, Robots, Space Gossip and More!
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
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...
+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.
my karma will be here long after I'm gone
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.
Thanks. Mods, lay some insightfuls on the man.
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
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
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.
Why is it so hard to only have politicians for a few years, then have them go away?
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).
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 ;)
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.
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.
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.
"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.
deleting the extra space after periods so i can stay relevant, yeah.
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.
Nullius in verba
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.
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?
Antonio Cromartie? is that you?
"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.
Have gnu, will travel.
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.
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.
“Common sense is not so common.” — Voltaire
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.
"""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...
That's about the same price as 50 Bayer aspirin at my local Walgreens.
You are welcome on my lawn.
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).
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.
... 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.
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....
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
upon the advice of my lawyer, i have no sig at this time
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.
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.
upon the advice of my lawyer, i have no sig at this time
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.
A successful API design takes a mixture of software design and pedagogy.
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.
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.
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.
http://michaelsmith.id.au
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.
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.
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.
Apocalypse Cancelled, Sorry, No Ticket Refunds
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?
which is totally what she said
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.
which is totally what she said
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.
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.
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.
Mexico: 100% conservative's America now!
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.
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.
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.
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.
You are welcome on my lawn.