How Can We Prevent This Medical Error?
A number of readers emailed me a link to this New York Times article: “U.S. Inaction Lets Look-Alike Tubes Kill Patients.” The headline emphasizes the lack of governmental oversight, but I'd rather talk about the poor system design that allows deadly errors to occur.
The article describes an error where food was mistakenly injected into her veins:
… 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.
So is this a one time fluke? It seems not:
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.
Why are errors rarely reported? That's a topic for a different post. I think the question here is why there's such a risk of systemic mixup.
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 â€” sometimes with deadly consequences.
Interchangeable, identical looking clear tubing – that's a mistake just waiting to happen, isn't it?
I saw, last week, a presentation about a chemical factory that had made huge strides in improving worker safety. One of the risk factors the engineers identified is that the pipes through the factory were all gray — somebody's idea of aesthetics. But, in an emergency, not having pipes clearly labeled could be deadly.
So if this is fixable in a chemical factory, why not in our hospitals?
It's not a new idea that there are systemic risks. Again, from the article:
Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible â€” 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.
It's often said that it takes 19 years for a change to make its way from idea to widespread implementation in healthcare. So we have a few more years left on that clock…
If it's far too easy to mistake a food line for an intravenous line, can't we fix that today? Isn't there an opportunity for simple labeling and visual controls? Do we really need to let the FDA get in the way of this? I'm asking a question I don't completely know the answer to — what do the clinical readers have to say?
One paragraph in the article that I agree strongly with is this:
“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.”
So when a systemic mistake occurs (one that's predictable), what happens? Often, a person gets blamed — and the article brings up the case of a nurse, Julie Thao, who was convicted after a fatal error (and I blogged about it a number of times over the fast few years).
The article talks a lot about failed legislative attempts and failed regulatory efforts — so my question (and there may be a good answer) is why hospitals don't each individually fix this tomorrow?? If we can't change the equipment, how can we change the process to avoid the error? Does the FDA really get in the way?
It's a shame we have this dynamic:
“The regulators have been waiting for the manufacturers to come up with a solution,” Ms. Pratt said, “and the manufacturers won't spend the money to design and produce something different until the regulators force them to. And now the international standards organization is taking forever to get the whole world onto the same page.”
Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, agreed, “These things are hard to change when you have to get so many different organizations to act in concert.”
I guess that makes it much more complicated than a chemical factory, which is also regulated? People are dying, unnecessarily, during this delay. How can we avoid this suffering?
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