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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
"because the agency is so worried about making industry happy, people continue to die"
I say bullshit.
Industry would be more than happy to sell new tubes to every single hospital in the country !
How about using color codes?
Or incompatible sizes or connections?
Damn... this is so easy to fix.
In chemical industry, and in labs, color codes have been used for the last 15 millennia or something. It's completely standard. Just a sticker or some tape at both ends of a tube, indicating it can only be used for that gas or liquid. And in the case of non-standard liquids/gases, standard labels (you know, those with text on it) are used to indicate what it's used for, and what is in it.
Sounds like they're in need of a Poka-Yoke project.
These problems have been going on since at least the 1970s.
And:
Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups.
Hundreds of deaths in the past 40 years doesnt sound like a really big problem.
My son has spent a lot of time in hospitals, he had a broviac catheter (venous) and during his frequent and long stays this has never been a problem. As a layman it was painfully obvious which tube went where.
A much larger issue, in my mind, was actually receiving the proper meds in the proper dose.
Unfortunately, the FTA says that some companies have internally consistent color codings, but other companies have pioneered their own color coding scheme. Even if the industry came together on a color coding standard, there would still be problems. The most obvious are color-blind nurses and doctors mistakenly connecting the wrong colors and accidental connections. Then there's the problem of internal consistency with colors. There's a reason Pantone is still in business. In my factory red comes out pretty close to Pantone 200. Due to differences in materials, production, dye quality, etc. your red comes out closer to Pantone 186. Both of those are pretty red, but next to each-other they don't look anything alike.
The simplest way to prevent this problem is what the OP suggests. Make the tubes physically incompatible and add a color code to simplify grabbing the right one. Even if the care-giver nabs the wrong tube, it won't be possible for them to connect it up.
I'm actually a little shocked to hear that this problem hasn't already been fixed. I suppose it has to do with the lengthy application and approval process for medical devices. Changing the ends or adding color probably requires an entirely new review by the FDA or some such agency.
This one's tricky. You have to use imaginary numbers, like eleventeen... --Hobbes
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.
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
So we need to make fail-proof nurses instead of making fail-proof tubes.
It's so much easier. Problem solved.
To fail is human. Even the best nurse will make mistakes after running around for 20 straight hours of work in an overcrowded, understaffed hospital.
Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard?
"look, I -understand- your heart has stopped, sir, but if you'll just be patient with me--heh, "patient"--I'll trace these tubes back to...the...appropriate bits of--OK, that's the one..."
Personal responsibility is a wonderful thing, but nurses a) often don't have the luxury of time, and b) like other human beings, occasionally make mistakes. Further, nurses don't have the luxury of an Undo command, and very, very slight errors can and often are fatal.
Obliteracy: Words with explosions
That's a great idea. Rather than making a few simple changes to the interface, we'll let the Invisible Hand solve the problem. Hospitals that hire nurses who make the occasional simple, human mistake will eventually go out of business. That's brilliant. I'm so glad we have Republicans around to show us the Right Way (tm) to do things.
No folly is more costly than the folly of intolerant idealism. - Winston Churchill
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.
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 ?
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
Pilots have extensive training and "know what they are doing", yet checklists are part of standard safety policies. Why? Because checklists save lives.
Does it matter if only 1 person a year dies from having a stupid mistake, if it happens to *you*, while you are having some silly routine procedure happen? Do you want to be the one who dies having an MRI because someone forgot to ask if you had any metal implants?
We could just say that malpractice judgments will incent people to do the right thing.. hey, wait...
maybe it is!
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.
And a silver band means 10 percent tolerance, and gold means 5!
Nobody has ever trained them how to effectively communicate patient state to their replacements.
Communication is the one thing that is harder for humans than thinking and remembering. The most important people management lesson I ever learned was playing the "Telephone" game as a kid: there's about 50% information loss on any transmission of even the simplest message.
A quick look at the documentation for your current project will suggest the same thing.
It is not surprising, therefore, that the leading cause of iatrogenic disease is mis-communication, not mistakes made by tired staff.
That said, the solution to the problem is overlapping shifts: nine hour shifts with an hour overlap, so the evening shift has an hour with the day shift still on, and so on. This--depth of time--is one of the most critical factors in effective communciation.
Blasphemy is a human right. Blasphemophobia kills.
I agree -- this is so critical that it not only should be part of licensing curricula, the institution-wide communication plan should be part of medical institution licensing as well. You need a license to run a hospital, with occasional checks for certain things, so it'd be easy to enforce it.
Unfortunately, it's not part of the culture, and it seems that otherwise rational top-notch doctors seem not to have a clue about it at all. Heck, they get all worked up against it whenever I mention the topic.
I also think that hospital f-ups should be reported and published the same as major transportation mishaps. Otherwise no one will learn any lessons, because none are to be easily found. A lot of malpractice and substandard care suits end up with a settlement with no admission of guilt -- and all of the details are not public. So even if I were to, say, prepare a course curriculum for doctors/medical administrators, there is little in the way of well researched examples to give. Compare that to teaching pilots: you could go over the accident reports forever, it seems.
A successful API design takes a mixture of software design and pedagogy.
Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard? If you're a nurse at a station and you want to ensure that you have the correct tubes. Take a moment and label them yourselves if you are that busy.
I would like to reply to this instead of marking it down as "-10 clueless" because people should read why it is clueless.
The goal here is not to find someone to blame when a patient dies, the goal is to reduce the likelihood of a patient dying in the first place. The goal here is not to find ways how to make a nurse take more time looking after a patient in order to do a proper job, because that only allows them to be pressured into rushing things when they have to meet goals like looking after so many people per hour.
You are going on about the personal responsibility of the nurse, what about the personal responsibility of their f***ing manager? One of the things a manager does is goal setting, and a very important aspect is not to set conflicting goals and arrange things so that a nurse trying to meet one goal will be on their way to meet the others. You are trying to make speed + safety contradictory goals, a sure recipe for disaster. Safety is best handled in such a way that it is unavoidable, not in such a way that it can be done away with to meet other goals.
Another principle that has served me very well while driving a car: People make mistakes. Accept that as a fact, no matter how careful they are, people make mistakes. In road traffic, mistakes only lead to accidents of other drivers don't manage to react to mistakes. So you do two things: Drive so that others can react to your mistakes and avoid accidents for you, and drive expecting others to make mistakes and fix them for them. (This also makes it a lot less stressful, when you take all the stupid things people do as just normal things and don't get excited about them).
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.
I've met girls with that kind of attitude to something potentially risky - "Just be careful".
Most of those girls are now mothers.
i don't know, but it reminds me of the scene from Idiocracy where the "Doctor" tells the protagonist to put one probe in his mouth and the other in his rear, then realizes he made a mistake and asks him to switch them.
http://www.youtube.com/watch?v=8CHY41trBFQ&feature=search
about 0:40 into the trailer.
"If still these truths be held to be
Self evident."
-Edna St. Vincent Millay
Ideally, nurses aren't working 12- and 14-hour shifts back-to-back because of critical understaffing and/or cost-cutting, and aren't responsible for about 2-3 times as many patients per nurse as they ought to be. Ideally, said nurses aren't fatigued and stressed to hell and gone. Ideally, no one ever makes a mistake when they are exhausted, rushed, and stressed. Ideally, if anyone makes a mistake, it will be completely innocuous and won't kill or maim anyone or cause massive property damage.
Unfortunately, I don't live in that ideal world, and neither do any nurses I know of. That doesn't make them "purely incompetent"; it makes them human beings living in the real world.
Based on this NY Times article, the current state of things in the medical devices world is fucking retarded! In the electronics world, we carefully make incompatible devices with incompatible plugs, and/or use color coding for similar plugs (keyboard/mouse and microphone/speaker/line-in come to mind). Apparently making sure customers don't fry their home electronics is more important than making sure patients don't die. Apparently the medical devices industry hasn't heard of something like "industry standards". How bloody hard is it to get together with your industry standards organization and publish a standard that says all IV tubes have a plug type A, all air tubes have plug type B, etc?? This is basic industrial and safety engineering--it's not rocket science.
---dragoness
Yeah, but that's bobbins though, isn't it? There's a reason airplane cockpits are designed the way they are. There's a reason nuclear power station control surfaces are designed the way they are. In fact there's a very good reason why anything that could really go bang has input devices that are designed to diminish the possibility of user error.
Just saying "pay attention" isn't enough. No-one, not you, certainly not me, can attend exactly to what they're doing for every second of every minute of every day.
I had a dream, bright and carefree, but now there's doubt and gravity
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.
You have no idea how bad it is in nursing. And I'm glad that your friends are in nice, cushy jobs that somehow maintained a certain standard. In many places all over the country, there are practically no nursing jobs available, but at the same time, there aren't enough nurses. How can that be? Well, there is either no money to pay them or nobody is willing to pay them. For the jobs that are available, they get filled easily by all of the older nurses delaying retirement or coming back from retirement because they need the money. As a result the job market is saturated with nurses with a lot of experience looking for work. Since employers know that they can get nurses with experience, they require at least a year of experience nursing minimum or they throw out the application. Very, very, very few nursing jobs are available to new grads. The ones that are available are typically reserved for someone because of connections. Then you have ads all over the place, and of course "conventional wisdom" telling people that there is a nursing shortage, and all they need is a nursing degree and they can get a job. Lies. All so that these nursing schools can make money.
So we have a situation with a glut of people with nursing degrees with no nursing experience, and nobody willing to give them nursing experience. At the same time we have an aging nurse population who will soon not be able to continue, and maybe even require nurses of their own. What a fucked up situation.
So imagine you are a nurse, and you know about this situation. You are stuck in a shitty unit in a shitty hospital, like in Detroit, and you are overworked and the family members of the patients are rude and yelling at you, you have over twice the "ethical" workload because there aren't enough nurses and you can't just not give people medical care after they are admitted or you will lose your job, and you rarely see the doctors and they disrespect you when you do see them. Everyone in the unit is asking why you are there because they job sucks so much. It is pretty fucking stressful. I think at that point if you make a mistake, of any magnitude, it is understandable.
Actually, harder than you might think. One of my coworker tells the story of when our company sat down the heads of several major hospitals to discuss.... bed pans.
The reason: each hospital in the network buys its own bed pans, from different vendors. It was realized that they would actually save a million or two a year by just, agreeing to buy one standard bed pan from one company together.
These big shots sat around for a couple of hours, and left the room with no decision. In fact, still to this day, they purchase bed pans separately.
Instead of saving millions, they wasted several thousand dollars "worth" of these highly paid executives time, and called it a day.
-Steve
"I opened my eyes, and everything went dark again"
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.
If these devices can be designed so this can't happen, then designers, manufacturers, etc. are also not taking responsibility for their actions. It's all well and good to point fingers at the end user, but if you built this stuff and you could have made it more foolproof and didn't, you failed too. It is not necessary of even advisable to have a device with only one layer of defense against misuse. This is a design flaw.
For an excellent example of this sort of design failure, see the Therac-25 case. Therac-25 case used to be taught in just about every system design class for a while. Unfortunately, this happened so long ago that programmers and s/w engineers forgot the lesson and a similar problems have happened again.
Everyone who designs anything that gets used by anyone should read The Design of Everyday Things to disabuse themselves of the notion that it's always the fault of the stupid, incompetent, careless, rushing, undertrained user.
Yes, it's harder. No, you can't anticipate everything. But every problem you can prevent is a person not frustrated, something not broken, money not wasted or even a life saved. So even if you can't do it 100% foolproof, it doesn't mean you don't try your damnedest. Because real users are human, frail, imperfect and subject to many, many pressures.
I am not a crackpot.
In the Denver area hospitals are frequently understaffed, but the hospitals refuse to hire many of the available nurses.
In particular the problem is that a significant percentage of new nurses can't get hired because there are policy (and regulatory? dunno) reasons that you can't have too high a percentage of staff being new graduates, due to their lack of experience. So new nursing school grads have a tough time getting hired around here.
My wife (a nurse) is involved in the training and orientation of new hires at her hospital, so she's relatively up on the issues. Also related is that there are some hospitals which are hurting financially due to the current general economic issues - a lot of that depends on the mix of patients and how they pay (insurance, if any, Medicare etc.)
There is also age discrimination for nurses in the opposite direction - my wife has been refused jobs because she's 'too old' or 'overqualified' etc. Not as bad as in the software world but it does exist.
Stupidity... has a habit of getting its way.
So far that I know of, having a "reverse convention" in all circuit diagrams everywhere hasn't gotten people killed yet. If you touch a circuit that is powerful enough to kill you, it won't matter what direction the current is flowing in vs. what direction it is labeled as flowing in on the diagram. Of course, feel free to point me to any sources/stories of a backwards convention in electronics directly resulting in a person's death.
Now, the case with tubes in the medical industry is not analogous. Is it convention to use all clear, indistinguishable tubes? Yes. Has this single convention demonstrably gotten people killed? Yes. Would it really be impossible to make sure all oxygen tubes were blue, all liquid tubes pink, and all gas tubes green, or something similar? No. Should, therefore, the convention be changed? Yes.
The the backwards current issue is about as benign as basing all of our coordinate mathematics of "right hand" conventions. It really doesn't matter in the large scope of things. The medical tube convention is similar to using the same interface plugs for audio wiring as is used for power jacks, it's a practical application that can lead to costly fuck ups.
Motorcycles, Robots, Space Gossip and More!
Now there are plenty of circumstances where standardization is called for...
I'm for it too. I don't know how old you are, but in my youth I spent a great deal of time building and troubleshooting 8086 systems. One of the biggest issues those days was figuring out which direction something was supposed to be plugged in. Connectors weren't keyed! A 24 pin connector was 2 rows of 12 pins and it could be plugged in either way.
Most external connectors were keyed (D-Sub connectors) but internal ribbon connectors, SIPP memory, and even processors could be plugged in the wrong way. If you were lucky, the manufacturer put a silk screened arrow pointing at pin 1, but that was most often not the case.
Standardizing tubing, or even standardizing tube labeling would be very helpful. Tracing lines might not be an option, why not mark them upon insertion?
I've been in both circumstances running data lines. I would much rather be involved in a job where each line was marked on both ends prior to installation. The alternative is a nightmare that at best takes forever and at worst, an eternity. I can't imagine being a nurse with a crucial medicine in hand tracing tubes.
"Lame" - Galaxar
How bloody hard is it to get together with your industry standards organization and publish a standard that says all IV tubes have a plug type A, all air tubes have plug type B, etc?? This is basic industrial and safety engineering--it's not rocket science.
It's very hard because to establish a standard, you need to demonstrate a need,
but a need implies a short-coming and of course known short-comings demonstrate liability.
Apocalypse Cancelled, Sorry, No Ticket Refunds
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
So nursing is just like every other profession then..
>Is it convention to use all clear, indistinguishable tubes? Yes.
The problem with your argument is that it is completely false. It is not at all a convention to use "all clear, indistinguishable tubes". IV tubing is clear. A nasal cannula for oxygen is maybe a little similar, but larger, more flexible, and (most importantly) uses a completely different Christmas-tree-type connector instead of a Luer adaptor. Nasal feeding tubes are similar in size to IV tubing, but are opaque and white. And so forth...
These devices really do look quite a bit different. Errors like this probably occur once in several thousand times they are used, and it is very hard to reduce "rare events" to "zero events". Nonetheless, the health care industry is highly sensitized to issues like this, and there has been a huge push to enact safeguards to make it even harder for such errors to occur.
Do you even work in health care or any direct knowledge of what you are talking about? (I'm a surgeon). It doesn't seem like it.
It is really telling that the Slashdot crowd mods something to "+5, Insightful" when the post is so factually clueless. I cringe whenever I see something related to medicine get discussed on Slashdot, because we invariably wind up with a bunch of smart IT guys giving opinions about things that they know very little about.
You have scientists and engineers who have long been using the incorrect convention and do not want to change because all of their work has been based on it. On the other hand, you have students who are trying to learn a model that is physically wrong, and they are wasting time and energy doing it. When you get to semiconductors, things REALLY suck.
No, we don't want to change because it'd take tons of work and is completely irrelevant. Students aren't learning anything wrong, they're just learning a convention for a unit. How much time and energy does it take to learn "Current is defined to be in the direction of positive current flow, but it's actually the negative charge carriers that move, so when you calculate a positive current in one direction, it means electrons are flowing in the opposite direction". Oh right, as long as it takes to say that sentence, and maybe explain why (because at the time the convention was made, we didn't know which it was that was actually moving, but we still needed a convention).
It doesn't suck for semiconductors at all, it's still irrelevant. For a MOSFET, you calculate your doping and number of dots/holes, calculate the amount of electrons that will flow across at a given source/drain/gate voltage, and then when you want to specify that flow in terms of current, you flip the sign. Woopty-fucking-do! To go from current to electron flow to analyze problems like electron migration, you just -- what was that again -- flip the sign. By the time you get to semiconductors, this should be utterly second nature.
If you wanted, you could get rid of the "wrongness" by simply defining current to be negative in the direction of negative charge movement, and not have to change a single calculation. It's mathematically and logically indistinguishable.
And then you get beyond talking strictly about currents through conductors, realize that a proton beam is a current in which -- GASP -- it's the positive charge carriers that are moving, so the "current is in the direction of negative charge movement" convention would be equally "wrong", and hopefully realize that it really doesn't fucking matter how you set your convention.
You just have to understand that some things that people say are more abstract than you may be able to comprehend. If you haven't spent time with microelectronics (many here have), this might not be your argument to fight.
Yeah, it's an abstraction with no practical consequence what-so-fucking-ever. Get over it!
If you're still lost, think about it this way. Medical equipment is a huge expense, and it's neither cheap nor trivial to just go in and replace it without costing the industry probably billions of dollars in the short term which means that you and I pay these billions of dollars. Got it?
Yeah, but not everything needs to be replaced. Connectors and tubes. Expensive, sure, but still completely unanalagous to the current convention. Lemme break it down for you:
Current convention:
* Affects every single current calculation done by electrical engineers, ever.
* Has absolutely zero real-world consequence
Medical tubing:
* Affects only a subset of medical devices.
* Has practical real-world consequences in the form of preventable deaths.
So, yeah. One is crazily expensive and not worth doing anything about regardless of cost because it is meaningless. The other is expensive, but doesn't require replacing everything, and has demonstrable value which must be weighed against the cost.
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The problem with your argument is that it is completely false. It is not at all a convention to use "all clear, indistinguishable tubes". IV tubing is clear. A nasal cannula for oxygen is maybe a little similar, but larger, more flexible, and (most importantly) uses a completely different Christmas-tree-type connector instead of a Luer adaptor. Nasal feeding tubes are similar in size to IV tubing, but are opaque and white. And so forth...
These devices really do look quite a bit different. Errors like this probably occur once in several thousand times they are used, and it is very hard to reduce "rare events" to "zero events". Nonetheless, the health care industry is highly sensitized to issues like this, and there has been a huge push to enact safeguards to make it even harder for such errors to occur.
If the adapters are different, how is it even possible for the error to occur? If there are some types of tubes that use different connectors such that they can't be connected incorrectly, but other types of tubes that aren't different and thus makes error possible, why not fix that subset? If the adapters are different, but not so different that you can't incorrectly stick them together, why not fix that?
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Based on this NY Times article, the current state of things in the medical devices world is fucking retarded! In the electronics world, we carefully make incompatible devices with incompatible plugs, and/or use color coding for similar plugs (keyboard/mouse and microphone/speaker/line-in come to mind).
Actually that's only been the case starting in the late 90s. Earlier than that, and you could get sound cards with nothing more than nearly invisible etched markings to indicate what the ports were for or completely unmarked keyboard/mouse PS/2 ports. And that's just outside the case. Inside, before mobo makers started catering to the build-your-own crowd, was a complete fucking nightmare. ATA disk cable connections didn't even have guides, much less a notch to prevent you from putting them in backwards. Oh, and the fucking AT power connector consisted of two separate connectors that went in side by side with nothing preventing you from hooking them up backwards, guaranteeing a short and the death of (at least) your mobo if you turned the power on.
The best part was when the manual had a typo when specifying pin 1 of a given connector. Oh yeah, those were fun times.
Anyway, I think my point is, even the electronics world took a while to get its shit together, and that was mostly inspired by an influx of amateur enthusiasts. I can't say I'm surprised that the medical profession doesn't aggressively leap on new standards when, because everyone is highly trained, the existing methods mostly work.
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