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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
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 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 ?
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!
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.
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
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
>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.