U.S. Inaction Lets Look-Alike Tubes Kill Patients

[mike r]

Source: New York Times

Thirty-five weeks pregnant, Robin Rodgers was vomiting and losing weight, so her doctor hospitalized her and ordered that she be fed through a tube until the birth of her daughter. But in a mistake that stemmed from years of lax federal oversight of medical devices, the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein. Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony. “When I walked into her hospital room, she said, ‘Mom, I’m so scared,’ ” her mother recalled. They soon learned that the baby had died. “And she said, ‘Oh, Mom, she’s dead.’ And I said, ‘I know, but now we have to take care of you,’ ” the mother recalled. And then Robin Rodgers — 24 years old and already the mother of a 3-year-old boy — died on July 18, 2006, as well. Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. 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. Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — 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... “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.”...

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 the confusion. 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, the manufacturers’ trade association successfully pushed legislation to delay the bill’s effects until the international standards group reaches a decision... Dr. Robert Smith, an F.D.A. device reviewer who left the agency on July 31 and was among nine agency employees who in 2009 decried the agency’s device approval process as illegal and dangerous, said that the tubing problem, which has gone on for decades, was another example of how the agency failed to protect the public. “F.D.A. could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,” Dr. Smith said...


Read more: http://www.nytimes.com/2010/08/21/health/policy/21tubes.html

[boppers]

1. I call PR bullshit.

Somebody's selling color coded tubes.

[Downwinder]

2. About time.

[Gormy Cuss]

5. From the article, one problem with color coding is not all manufacturers use the same scheme.

Changing the connectors to make them specific to certain devices AND color coding would probably go a long way towards minimizing mixups.

[boppers]

10. Is it a free scheme, or some asshole with a patent on "colors on wires"? eom

[Name removed]

12. Deleted message

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[Name removed]

14. Deleted message

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[CreekDog]

22. it's an effective safety practice to engineer out an easy to make mistake

think of how syringes have been re-engineered to protect health care workers in recent years.

very effective.

not everything is a conspiracy.

[Hannah Bell]

3. Um, instead of putting a tube down the patient's nose (an actual tube placement), the nurse

connected a tube feeding line to an IV line?

That doesn't even make sense. If you have orders to place an ng tube, you're not going to hook it to an IV line.

Something wrong with this story.

[Orrex]

4. I agree--it's like saying "Oops, I fed the gas pump into your transmission fluid."

One has nothing to do with the other.

[mike r]

7. Misconnections are a 'persistent occurrence' in hospitals

http://www.mddionline.com/article/unraveling-misconnections-medical-tubing

The nonprofit Joint Commission, a hospital accreditation agency, issued an alert to healthcare organizations in 2006, warning that misconnections are a “persistent and potentially deadly occurrence.”... More than 1200 times in the past 10 years, U.S. hospital workers have inadvertently connected tubes meant to link one device or system—an IV, a feeding tube, a catheter—into another device, frequently causing harm and sometimes death. But these figures may represent just a fraction of the total incidents. That's because they are based on voluntary, anonymous reports from only 15% of the country's 5800 hospitals...

[Mojorabbit]

21. There is no excuse for it.

You never hang anything without checking where you are connecting it to first. Ever.
Still a standardized color scheme would not be a bad idea.

[AllyCat]

23. There is an excuse. I know the RN involved in the epidural-medication-in-IV

mix-up. It was a horrible case that made us completely review everything we were doing. What happened there would be so EASY to do, particularly when one is really tired. She has 4 kids and is a single mom, trying to pull extra shifts to make ends meet. To be charged with a CRIMINAL charge was unbelieveable.

I'm not sure how some of this happens as our hospital has so many safeguards in place. I always check my lines...but after the Jasmine Gant accidental death, I think about her every time I hook something up. But when in a hurry, I can see how it happens. We need to eliminate these risks from something preventable...except when fought by the industry itself in the name of "making a buck".

[Gormy Cuss]

26. My friends and relatives who are nurses agree: being really tired is an underlying problem

and the other big problem is overload (too many patients.)

It's absolutely worth discussion of whether standardized color schemes and different connectors should be adopted.

[Hannah Bell]

48. yes, overwork is the real problem, but most of the errors in the article have nothing to do with

connections, they have to do with small doses of meds bolused by syringe into the wrong line.

overwork, short staffing is the real problem, and it's the problem they're not *going* to fix. it's going to get worse, because it's PROFITABLE. color-coding lines is just another PROFITABLE worthless fix -- mandate that all lines be color-coded so everyone has to change production & the government has to buy the product -- and increase short-staffing -- which will worsen the problem of small doses of meds being BOLUSED into the wrong lines.

[Hannah Bell]

31. you misunderstood what i'm saying. the article says: " Instead of snaking a tube through Ms.

Rodgers’s nose and into her stomach"

That's a tube *placement*. Not a connection error. The article doesn't make sense.

[mike r]

32. I see your point

It was indeed a placement error in that the NG tube was not placed into Ms. Rogers's nose. Now "the nurse instead coupled the liquid-food bag to a tube that entered a vein." I believe the idea here is for the manufacturer to idiot-proof the vein tube connector to prevent it from accepting the NG tube - to make the various tubes mechanically incompatible.

[Hannah Bell]

33. the article speaks of the ngt & the food bag tube as though they were the same tube. they're not.

the article doesn't make sense, such that it's impossible to know what happened, or if they just made up this particular story.

the nasal-gastric tube & the feeding bag tube are two separate tubes, which can be connected to each other. you don't "snake a feeding bag tube" down someone's nose. you attach it to an already placed ngt.

[Downwinder]

34. From the OP it looks like a procedure error rather than a tube mix up.

"But in a mistake that stemmed from years of lax federal oversight of medical devices, the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein."

It's the NYT do you expect accuracy?

[Hannah Bell]

35. no, but the lack of accuracy makes me question the entire story & why it appears at all.

i'm sure there are errors where tubes are misconnected. but it's not usually as easy as they're making it out, especially iv v. feeding tubes, & this story is a mess.

[Downwinder]

36. There is another case in the OP and we have enough comments

recognizing the problem to know a problem exists.

I didn't think anybody could mistake an Oxygen bottle for a Nitrogen bottle, but I was proved wrong. According to Murphy's Law if there is a possibility for error, it will happen.

[Hannah Bell]

38. whatever, dude. the article is a mess & there's always a possibility for error when humans

are involved.

the more complicated the system, the more possibilities.

witness the nyt's phoned in journalism.

[mike r]

37. This is not an uncommon occurrence: 1,200 times in the past 10 years

is the statistics reported by the healthcare industry, which admits that's just a fraction of the magnitude of the problem. The technical wording in the article might be unclear, but I have no doubt the Rogers incident occurred. In fact, there are plenty of horror stories on the web about feeding tube mix-ups. For example:

http://www.meyersmedmal.com/article-hospital-mistakes.html

Pittsburgh Post-Gazette, October 24, 1993

Orlinski, a 75-year-old retired steelworker, was killed in January when a first-year nurse inadvertently attached a feeding tube to an intravenous or IV line at Orlinski's wrist. The milkshake-like fluid meant to nourish Orlinski instead surged into his bloodstream, clogging his lungs and killing him within minutes. The script sounds hauntingly familiar to the family of Cynthia Tigner. Tigner died in 1985 at age 22 at Ohio State University Hospital in Columbus after a nurse confused her feeding tube and IV lines and put Maalox directly into her bloodstream. Tigner, who had been under treatment for a brain disease, left behind a husband and 15-month-old son. That same year, according to Allegheny County's Perper, a 77-year-old man being treated for cancer of the esophagus at a Pittsburgh hospital was killed when liquid nutriment was put into his bloodstream. And less than six months before that, in the fall of 1984, a similar mistake in Cleveland involving a 64-year-old patient was caught in time and the man wasn't harmed. Surgeon Thomas Stellato, later reporting the case in a medical journal, recommended special connectors for feeding lines to prevent them from being connected to intravenous lines. More than eight years after his article appeared, Stellato said in a phone interview that "I can't really say there's been any obvious changes." Similar mix-ups surfaced almost every year since Tigner's death in 1985, including:
-- On April 23, 1986, a San Diego nurse administered a mineral supplement into a woman's central line catheter. The patient died.
-- In December 1988, a young boy at Phoenix Children's Hospital was given cold medication meant for his gastric line in his central IV line and died.
-- In 1989, a Richmond, Va., Memorial Hospital nurse inadvertently put liquid nourishment in a patient's central line and Dilantin, used to control seizure disorders, in the feeding line. No information was available about what happened to the patient.
-- On Jan. 14, 1992, a 49-year-old woman at University of Wisconsin Hospital and Clinics in Madison died minutes after a pharmacy technician administered Metamucil -- a laxative -- in her IV line...

At any rate, this is an old problem - but a "trivial engineering issue" - that never got fixed.

[Downwinder]

39. How do you get things fixed? I think that is the real problem.

How many law suits did McDonald's have over superheated coffee, before the NM jury made an example of them?

[mike r]

41. Maybe a celebrity death

or something big?

Manufacturers have been taking advantage of the regulatory spaghetti and inertia in the FDA for too long, and the FDA must take charge. Get everyone in a room and force them to agree to a standard, or else impose a standard on them. This is not rocket science. People shouldn't have to die for something preventable like this.

[Downwinder]

47. Nobody would like my solutions. I have to agree in part with both you

and Hannah. Until patients become people rather than numbers on a spreadsheet I don't see any solution, except a budget breaking celebrity law suit that can't be passed to insurance or taxpayers.

[Hannah Bell]

40. not a simple engineering issue. The list of supposed "connection errors" in the article - aren't.

"Tigner died in 1985 at age 22 at Ohio State University Hospital in Columbus after a nurse confused her feeding tube and IV lines and put Maalox directly into her bloodstream."

That's not a tube connection issue. That's a nurse syringing a small dose of non-IV meds into an IV line. That's a human error.

Some meds are meant to be given IV, some oral/gastric. Small doses are bolused into all types of lines with a syringe-type thing, not administered by connecting a meds bag to a line.

The nurse choose the wrong kind of syringe or confused the medication -- not an engineering issue, not a connection error.


all the rest of the examples on the list are the same error: a small dose of meds bolused into the wrong place: not a matter of connecting the wrong tubes. nursing errors, not engineering errors, and they can't be fixed through engineering.


here's a man with a central line: for IV feeds, chemo, things that go into the blood. The three things dangling are the connection points.




here's a peg tube, the most common type of feeding tube: for things that go into the gut.




here's an ng tube with a syringe:




in all types, small doses of meds are bolused into the lines with a syringe-type thing.

now do you see why the error is human, not bad engineering?

10 to one the real issue = poor training or overwork.

[Downwinder]

42. Can you reduce the problem with engineering? Like having one plug

that fits you cell phone and a different incomparable plug what fits your printer. Can you reduce the fatigue factor with better working conditions for health care workers? Or do you just ignore it and hope it does not happen? The ignore does not seem to be working.

[Hannah Bell]

45. it's not a connection issue. you're not understanding. The list of errors all involved small

doses of meds. Small doses of meds are administered into lines with a syringe, they're not administered by connecting one line with another line going into a med bag.

The syringes aren't all the same, the ports aren't all the same, the connection points aren't all the same, but the nurse has to:

1. Know which line is which
2. Choose the correct syringe
3. Know what the med is and where it goes


You *could* reduce such errors with better training & staffing. Staffing these days is the real problem -- IMO. people (nurses/docs) are overworked, have too many patients. training also has some real problems.

But improving those ain't profitable. goods -- especially new goods that entail scrapping the old goods & getting guaranteed government money -- are profitable.

It's a problem of capitalism trying to make medicine a profit center. I'm very serious. The care system isn't designed for humans, it's designed for capital, and adding new "connections" isn't going to help -- like all the rest of the "fixes" they've "engineered" -- all those fixes are basically in aid of allowing them to short-staff to make more money.

[mike r]

43. The idea is to idiot-proof those connectors

so when (not if) people make a mistake, nothing bad happens.

The experts quoted in those articles stated that this is a trivial engineering problem.

[Downwinder]

44. The Air Force's T-37 was fool proof, but not idiot proof. With enough effort

you could crash it.

[Hannah Bell]

46. I'm a dietitian who does tube feedings and IV feedings. It's not a connection issue.

Sorry you don't believe me, but the article is crap.

It's not a "trivial engineering problem," I don't care what the article says.

Small doses of meds aren't administered by "connecting" things, they're administered with a syringe. And most of the errors in the article involve small doses of meds -- & i'd bet most of those 1200 supposed "connection" errors do too.

Human error, not engineering. The nurse has to:

1. Not mistake the med
2. Chose proper syringe
3. Chose correct line

Even the nightmare logistics of packaging hundreds of different med types & doses into individual single-dose syringes for IV or gastric ports wouldn't overcome the problem of mistaking the med.

The real problem is training & overwork.

[Chulanowa]

9. If you knew how many incompetent fucks work in the health care indistry...

You would probably end up hiding in a shack and doing your own dentistry.

No offense meant to DU's health care providers, or the greater community of such people, I know most are great people who are very, very careful at their jobs. Just that I'm very aware of the fact that there's no shortage of derp-derp-derp dunderheads milling around in hospitals and other health care facilities, and that short-staffing just makes the problem worse.

[azurnoir]

18. I work in health care and am familialr with both G and J tubes (feeding tubes)

and with the type used for IV and there was more than a "mix-up" here first off feeding tubes are huge at least 2 to 3 times the size compared with normal IV tubes and once inserted feeding tubes are supposed to flushed with saline while the nurse or whom ever is doing the insertion is listening with a stethoscope on the patients belly to make sure that is where the tube is, not to mention anatomically speaking an open vein big enough to allow for the insertion of a feeding tube is just not located on the path that it should take something went horribly wrong here and there was some incompetence to say the least involved

[Chulanowa]

20. I was banking more on "negligent stupidity" than simple incompetence

I've heard stories of nurses where I work disconnecting feeding tubes "because the resident is full"

Said nurses were fired asap, of course. it's the fact that it was PLURAL that scares the living piss out of me.

Granted this was years before I started there, but jesus

[Abq_Sarah]

17. yeah

Color coding tubes so that healthcare workers don't have to understand what in the hell they're doing as long as they put blue with blue doesn't exactly inspire confidence.

[northernlights]

24. just for the record, color coding

isn't about not knowing or understanding what you are doing. Color coding is about identification of things that can look very, very much alike, especially when you are on the run. It's much easier to quickly identify blue/blue than to look for tiny writing giving the size or contents or type of tube. Especially if somebody has multiple tubes sticking out of them -- do you think it would be better to have someone crawling all over you, poking around, trying to read writing on the opposite side of a tube as is facing out, jostling the tubes, possibly accidentally pulling them apart?


"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. Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, ..."


(I'm a med lab tech student, and in the case of the tubes used for drawing blood in phlebotomy, the venal collection tubes look *exactly* alike. The color in those cases identifies exactly what additive is or isn't in the tube. And what's scary is that there is some variation depending on the manufacturer. There should be a single color code to learn. It's enough to memorize 20 different random colors with as many different additives. And then the capillary tubes have a different color scheme -- the opposite of the venal. It's unbelievable stupid and nonsensical. If red means no additive on one type then it should mean no additive on the other. If green is heparin on one, it should be heparin on all.)

[Abq_Sarah]

27. Well

I'd rather they physically traced the tube to make sure they're using the correct substance in the correct tube. Depending on color coding ducks the responsibility of knowing exactly what you're doing.

[Downwinder]

28. You have different plugs for different voltages. Makes sense, doesn't it? n/t

[northernlights]

30. then I suggest you go through nursing school

get an advanced degree in nursing, and practice in the real world for a few years. Once you actually know entire protocols, how and why things are done the way there are, and move into the top nursing positions, then you'll be in a better position to argue for new and improved protocols. :shrug:

[superconnected]

6. Horrifying. Poor woman!

[bc3000]

8. The quality of our regulatory agencies is turning me into a libertarian.

why bother?

[Chulanowa]

11. Because nothing is not greater than something

See, libertarians suck at basic math. 1 > 0, always. This is why we have to keep them away from our economic system.

[boppers]

13. -1 is greater than 0?

Uh, no.

On edit:
Nothing does nothing, but negative does something.

Zero does zero.

[Chulanowa]

15. See, that doesn't even make any sense

Could the regulations be better? Absolutely. But that would be 200 > 1. or 5 > 1. But one is still more than zero. it is in fact infinitely more than zero.

Poor regulation is still better than no regulation. Far from ideal, but far and away MORE ideal than nothing.

Go smoke your bowl and try to blow someone else's mind.

[boppers]

16. Phd on math fail. eom

[Chulanowa]

19. Don't worry, you'll do better

I'm sure even Stephen Hawking has his dumbass days.

[northernlights]

25. you need to check your eyesight.

The post you are referring to does NOT say "-1>0"

It says 1>0. Which it is. +1 is greater than zero. Always. A single regulation is greater than no regulations.

(at least numerically. if it's a bad regulation, we're better off with no regulations. and if it's not enforced, then good or bad it's irrelevent. but that's a different topic.)

[Odin2005]

29. Google "Regulatory Capture"

An agency controlled by the people it is supposed to regulate is worse than nothing.

[Selatius]

49. We have no other choice but to try to recapture the regulatory agencies. Otherwise, deaths occur.

Is that simple enough to see?