Medication errors are deadly--but so are look-alike tubes

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

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.

First the baby and then the Rodgers herself died. With so many tubes connected to a body that look alike, and the chronic overwork seen in nursing, it is so easy to make a deadly mistake.

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.

“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.”

Performance improvement principles in hospitals these days, in my experience, focus on trying to change the system to make it difficult for mistakes to happen, rather than lay the blame on the person making a mistake (this does not mean that willful acts, however, are treated the same...that's a whole other kettle of fish). But both the Joint Commission, a major accrediting agency, and the hospitals that follow their standards, try to come up with ways to prevent injuries or deaths. You can label the tubes, educate personnel, etc. till you're blue in the face, but the fact of the matter is as long as 1) they look alike and 2) fit together interchangeably there will be problems. The FDA and manufacturers really need to get on the ball about changing that.