14 years later, simple life-saving idea still in limbo

The New York Times reports on a simple solution to a problem that is killing many hospital patients. The problem:

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….

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.

Another tragic example:

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.

Her baby died, “And then Robin Rodgers — 24 years old and already the mother of a 3-year-old boy — died on July 18, 2006, as well.”

The simple solution has been obvious for at least fourteen years, yet nothing has happened:

Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible…

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.

Posted by James on Tuesday, August 24, 2010