Deadly errors made with tubes attached
NEW YORK – Alarm bells have been
sounded in the United States about a troubling source of medical
mistakes - tubes and lines that are inserted into patients for different
purposes look much alike, so much so that nurses will sometimes connect
an intravenous line to a feeding bag, or vice versa. This kind of error
can be fatal.
In a recent article, The New York Times highlighted the case of Robin
Rodgers, a pregnant woman who was hospitalized because she needed a
feeding tube. In a mix-up, a nurse attached the feeding bag to a tube in
a vein - resulting in the death of the baby and mother.
The article pointed out that lines entering the body appear to be
interchangable – causing a good deal of confusion. “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.”
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 Julie Thao, a nurse at St. Mary’s Hospital in
Madison, Wis., mistakenly put a spinal anesthetic into a vein, killing
16-year-old Jasmine Gant, who was giving birth.
Ms. Thao, who had worked two eight-hour shifts the day before, was
charged with felony neglect. She pleaded no contest to two misdemeanor
charges. But experts say such mistakes are possible only because
epidural bags are compatible with tubes that deliver medicine
“This is a deadly design failure in health care,” said Debora Simmons, a
registered nurse at the University of Texas Health Science Center who
studies medical errors. “Everybody has put out alerts about this, but
nothing has happened from a regulatory standpoint.”
An international standards group is seeking consensus on specific
designs on how tubes for different bodily functions should differ, but
the group has been laboring for years and its complete recommendations
will take years more. Some manufacturers have used color-coding to
distinguish tubes for different functions, but with each manufacturer
using a different color scheme, the colors have in some cases added to
Researchers have identified hundreds of deaths resulting from tube
mix-ups, but the real toll is unknown because errors of this kind are
Still, a 2006 survey of hospitals found that 16 percent had experienced
a feeding tube mix-up.
Experts and standards groups have advocated since 1996 that tubes for
different functions be made incompatible – just as different nozzles at
gas stations prevent drivers from using the wrong fuel.
But action has been delayed by resistance from the medical-device
industry and an approval process at the Food and Drug Administration
that can discourage safety-related changes.
Hospitals, tube manufacturers, regulators and standards groups all point
fingers at one another to explain the delay. Hospitalized patients often
have an array of clear plastic tubing sticking out of their bodies to
deliver or extract medicine, nutrition, fluids, gases or blood to veins,
arteries, stomachs, skin, lungs or bladders.
Advocates in California got legislation passed in 2008 that would have
mandated that feeding tubes no longer be compatible with tubes that go
into the skin or veins by 2011. But in 2009, AdvaMed, the manufacturers’
trade association, successfully pushed legislation to delay the bill’s
effects until 2013 and 2014 or until the international standards group
reaches a decision.
In the meantime, F.D.A. reviewers have begun to question whether feeding
tubes that could mistakenly be connected to intravenous tubes should be
declared fundamentally unsafe.
Posted August 26, 2010