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Look-Alike Tubes Lead To Hospital Deaths

timothy posted more than 3 years ago | from the no-wait-this-one-goes-in-your-mouth dept.

Medicine 520

Hugh Pickens writes "In hospitals around the country, nurses connect and disconnect interchangeable clear plastic tubing sticking out of patients' bodies to deliver or extract medicine, nutrition, fluids, gases or blood — 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, and in 2006 a nurse at in Wisconsin mistakenly put a spinal anesthetic into a vein, killing 16-year-old who was giving birth. 'Nurses should not have to work in an environment where it is even possible to make that kind of mistake,' says Nancy Pratt, a vocal advocate for changing the system. Critics say the tubing problem, which has gone on for decades, is an example of how the FDA fails to protect the public. 'FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,' says Dr. Robert Smith." This reminds me of the sort of problem that Michael Cohen addressed in a slightly different medical context (winning a MacArthur Foundation grant) a few years ago.

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Its not just the internet (5, Funny)

maroberts (15852) | more than 3 years ago | (#33367310)

..that's just a series of tubes, then

Re:Its not just the internet (1)

DWMorse (1816016) | more than 3 years ago | (#33367316)

This problem is tubular. Dude.

Re:Its not just the internet (1)

mcgrew (92797) | more than 3 years ago | (#33367492)

"In hospitals around the country"

Which country? Internet tubes are international. But yeah, I can guess, it's my country... do they have these problems in other countries?

And what idiotic engineer (or more likely his idiot manager) had tube connects for different purposes that fit the same fittings?

And speaking of tubes, we're all series of biological tubes. There was a band back in the '80s called "The Tubes" that were named after this phenomena.

Re:Its not just the internet (1)

PopeRatzo (965947) | more than 3 years ago | (#33367526)

And speaking of tubes, we're all series of biological tubes.

Wait, they're supposed to be connected in series? My tubes are connected in parallel.

How about (0)

Anonymous Coward | more than 3 years ago | (#33367312)

Color codes and making it impossible for two of the wrong type of 'tubes' to ever be connected. size/shape/connector...

Send me my check now...

Re:How about (1)

somersault (912633) | more than 3 years ago | (#33367328)

I think colour coding alone would be enough, and way more cost effective than having different types of tubes for everything. Well apart from for the male nurses, who are far more likely to be colour blind..

Re:How about (4, Insightful)

txoof (553270) | more than 3 years ago | (#33367418)

Unfortunately, the FTA says that some companies have internally consistent color codings, but other companies have pioneered their own color coding scheme. Even if the industry came together on a color coding standard, there would still be problems. The most obvious are color-blind nurses and doctors mistakenly connecting the wrong colors and accidental connections. Then there's the problem of internal consistency with colors. There's a reason Pantone is still in business. In my factory red comes out pretty close to Pantone 200. Due to differences in materials, production, dye quality, etc. your red comes out closer to Pantone 186. Both of those are pretty red, but next to each-other they don't look anything alike.

The simplest way to prevent this problem is what the OP suggests. Make the tubes physically incompatible and add a color code to simplify grabbing the right one. Even if the care-giver nabs the wrong tube, it won't be possible for them to connect it up.

I'm actually a little shocked to hear that this problem hasn't already been fixed. I suppose it has to do with the lengthy application and approval process for medical devices. Changing the ends or adding color probably requires an entirely new review by the FDA or some such agency.

Re:How about (1)

click2005 (921437) | more than 3 years ago | (#33367560)

Theres also the issue of colour affecting the look of the stuff being moved. A reddish tube might make someone think
there was blood in another fluid. It would have to be transparent enough to see the liquid inside clearly.
Stripes of colour along a tube might not be seen.

I suggest they invest in the no-kink spiral stuff that case modders use in watercooled PCs.
Wouldn't you visit a hospital more if all the drips had a glow under UV light?

Re:How about (1)

Chrisq (894406) | more than 3 years ago | (#33367620)

Theres also the issue of colour affecting the look of the stuff being moved. A reddish tube might make someone think there was blood in another fluid.

You could have coloured bands round a tube, with the connectors also being colloured.

Re:How about (1)

MichaelSmith (789609) | more than 3 years ago | (#33367582)

I'm actually a little shocked to hear that this problem hasn't already been fixed

It doesn't surprise me. Medicine hasn't taken on process definition the way most other industries have. I doubt most medical environments would qualify for ISO9001, let alone anything more prescriptive.

Case in point, when my wife was in hospital after giving birth to our son she sat up to breastfeed and started to slip off the chair she was in. Because she was recovering from a C-section she was unable to lift herself up so she pressed the call button for a nurse. Nobody came. Different nurses no doubt walked past the room and assumed that responding was Somebody Elses Problem. My wife eventually called the hospital from an outside line, got reception and they sent somebody up to help her.

One of the QA managers where I work had a similar experience when we was in hospital.

I think the reason is that doctors and nurses think they know everything which they need to know and no outsiders are going to tell them anything different.

Re:How about (1)

tomhudson (43916) | more than 3 years ago | (#33367638)

Being color-blind doesn't mean what you think. Red-green color-blindness doesn't mean you can't tell the difference between a red light and a green light, or between a stop sign and grass.

Besides, there's no reason why a 2-color band can't be used. White-Red-Orange-Yellow-Green-Blue-Black gives 7 colors. So, you'd have 7 1-color bands, 6+5+4+3+2+1 (21) two-color bands, for a total of 28 combinations. That should be more than enough to start with.

Re:How about (2, Insightful)

PopeRatzo (965947) | more than 3 years ago | (#33367580)

I think colour coding alone would be enough, and way more cost effective than having different types of tubes for everything.

You're worried about the expense of using different types of tubing and connectors? Here in the US, where you might pay $50 for an aspirin, and $1200 for a common, very standard blood test that actually costs about $15 in lab costs, I don't think the connectors are going to be the problem.

By the way, the second example of the $1200 blood test, comes from personal experience.

At least in this country, nothing in health care costs is tied to anything like reality. For all we know, the insurance companies might claim that having hospitals use different types of tubing will triple health care costs across the board.

Re:How about (1)

glueball (232492) | more than 3 years ago | (#33367818)

Don't worry. Based on my experience working in medicine, in the future you will not get a $50 aspirin or a $1200 lab test. You will see your GP who will tell you to go home, put down your cheeseburger, go for a walk, take your own aspirin and call him in the morning.

There are two things that work in medicine. Surgery and antibiotics. Everything else treats symptoms or confirms you need either surgery or antibiotics.

Re:How about (2, Insightful)

wjousts (1529427) | more than 3 years ago | (#33367366)

And surely different color tubes (and/or sizes/connectors) would make industry happy. More sales of medical tubing if you can't interchange them.

Re:How about (2, Interesting)

kenh (9056) | more than 3 years ago | (#33367688)

'FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,' says Dr. Robert Smith.

Yeah, exactly - the FDA could change EVERY CONNECTOR on every medical device that uses tubing "tomorrow" (I assume you meant that metaphorically, not literally Dr. Smith), ignoring that changing each connector on, say, an air pipe, would require a recertification of the device. How many connecotrs in each hospital room would have to be changed? Doctor's office? Operating rooms? Ambulances? And how long would it take the industry to respond with retro-fit kits and sufficient inspectors to review all the work required, let alone the lead time needed to manufacture, distrubute and use all the new tubing required...

Re:How about (1)

kestasjk (933987) | more than 3 years ago | (#33367768)

I love how the summary and focus here is on making the nurses and the industry happy ("nurses shouldn't have to work in an environment where this kind of mistake can be made"), yet no-one mentions the slightly disconcerting possibility for a patient of having a blood-pressure air-pump tube hooked into a blood vein..

Oh god that's horrible.. I'll have that in my mind whenever I get a drip put in now.

Re:How about (0, Troll)

kenh (9056) | more than 3 years ago | (#33367524)

By requiring that every connection/tube be a different color/size, you've now made medical care even more expensive than it already is - hospitals will be forced to stock all manner of spare parts, in sufficient qty for all possible applications - they will no longer be able to stock a huge spool of bulk tubing and cut it down for the application required... Sounds like a trivial expense increase right? But the hospital will have to have somewhere to store all these unique parts (build a storage facility, for example), they'll have to man it 24x7 (that's a minimum of 4 full time employees), plus have some way of inventorying and distributing the unique parts to all places in the hospital (a group of orderlies with carts, say another 10-15 full time jobs for a regular sized hospital, again to allow for 24x7 coverage), and let's not forget the increased expense of each specialty part when compared with the cost of a length of tubing cut off a huge spool of PVC medical-grade tubing.

But hey, we'll have lowered the bar on the nurse's job - you know who nurses are, right? They are the ones that went to college for four years, then went on for a nursing certificate and worked for months/year to learn how to do their job and not make mistakes, but heck, we can't hold them responsible for actually paying attention and doing the right thing...

I can just imagine the scenario now - "Sorry, we'll have to reschedule your open-heart surgery because we've run out of magenta anesthesia tubing with the square fittings, and trust me, you're gonna want anesthesia for that operation - we sent Jimmy over to the hospital on the other side of town to see if they can spare an appropriate tube..."

Re:How about (5, Insightful)

C0vardeAn0nim0 (232451) | more than 3 years ago | (#33367612)

stock a huge spool and cut it in place ???

are you fucking insane ? hospitals are not datacenters, dude. those tubes need to sterilized in well equiped facilities, then wrapped in sterile bags that can only be opened when it's time to use.

do their job and not make mistakes,

ok, now i know you're a troll. obviously you never worked anywhere where you could be subject to enourmous pressures, having only a split second to make a vital decision. if you had, you'd know that under those circumstances, even the best trained professional can make mistakes. nurses are human beings, not machines.

Re:How about (2, Insightful)

radtea (464814) | more than 3 years ago | (#33367686)

I can just imagine the scenario now

Unfortunately for your imagination, it has decided on a scenario that has been the actual case for decades: gas couplings in the OR are in fact unique so, for example, oxygen and anesthesia cannot be confused with each other (this is the case in Canada, at least).

And strangely enough the disaster you fantasize about hasn't happened.

Maybe you're just a fearful conservative making shit up to save yourself the dreadful pain of dealing with change.

Thinking out of the box (5, Insightful)

fph il quozientatore (971015) | more than 3 years ago | (#33367318)

We should have the tubes manufactured by the same companies that produce battery chargers for mobile phones. Problem solved!

Re:Thinking out of the box (5, Insightful)

pesho (843750) | more than 3 years ago | (#33367362)

I know you are making a joke here, but somebody should mod you up as 'Insightful'. Having incompatible fittings at the ends is the easiest and safest solution. Color coding as somebody else suggested is harder - you need to prove to FDA that the color is safe and does not leach from the plastic, and it isn't as safe - people are dumb they will connect the red tube to the blue outlet if they can.

Re:Thinking out of the box (3, Informative)

characterZer0 (138196) | more than 3 years ago | (#33367410)

And the National Association of Colorblind Nurses will sue.

Re:Thinking out of the box (3, Funny)

corbettw (214229) | more than 3 years ago | (#33367662)

Nah, women are rarely colorblind.

<whispers in background>

Wait, there male nurses now? When did that happen?

Re:Thinking out of the box (5, Informative)

yamfry (1533879) | more than 3 years ago | (#33367534)

This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.
I work in a hospital -- in the pharmacy, not nursing. I can't be sure that this is generalizable to other hospital systems, but we already do have incompatible connections for almost every route. You can't connect an IV line to an oral syringe. You can't connect a gastric feeding tube to an IV line. They just don't fit.
In cases where injectable drugs have potentially dangerous routes, we have other safeguards -- if a drug is to be injected intrathecally (into the spinal fluid), there is a giant, black sticker on it that essentially says "Hold on. Take a second and review everything. This is serious business." If it is commonly given with another drug that is given intrathecally, it comes double-bagged with a giant label that says "DON'T GIVE THIS INTRATHECALLY OR SOMEBODY WILL DIE".
I don't know that these practices occur across the US, but I'm pretty sure that there are at least products on the market that do all of these things. Without the FDA making new laws.
In many cases it comes down to the resourcefulness of the nurse. I have heard of at least one case of a nurse who gave an enteral feeding intravenously. The connections were incompatible. Her solution was to attach the two ends together and keep them in place with surgical tape.
One exception that I know is a problem is in the neonatal arena. It is a specialized area without a whole lot of specialized equipment in some cases. For instance, the enteral feeding is sometimes so small and required to go so slowly that the only alternative may be to put it into an IV syringe and run it through a syringe pump. This is (and has been) a recipe for disasterous outcomes.

Re:Thinking out of the box (1)

kenh (9056) | more than 3 years ago | (#33367742)

This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.

Me thinks that Nancy Pratt and Dr. Smith are hoping for their 15 minutes of fame with this Y2K-like "catastrophy" - I'd hate to think a reporter didn't fully investigate the claims of the subject they are reporting on...

Re:Thinking out of the box (0)

Anonymous Coward | more than 3 years ago | (#33367546)

Everyone here is saying how "obvious" it is that they should have incompatible fittings. While it seems like a great idea, it's really not that simple. If such a plan was implemented, we'd be reading another article in a few years about how many people died because a doctor or nurse couldn't find the right type of tube in time, or how two incompatible tubes that looked similar ended up leaking medicine all over the floor instead of into the patient.

Color coding isn't a bad idea, but there are hundreds of different things that can go into a tube, so it doesn't really solve the underlying problem. Right now a nurse looks at a bunch of identical tubes, and can make a mistake of which is which. With color coded tubes, you'd have a nurse having to stop and think "OK, does morphine go into the fuchsia tube or the mauve one?"

Re:Thinking out of the box (0)

Anonymous Coward | more than 3 years ago | (#33367576)

Uk researchers have been working on one possible solution to this: http://www.lab4living.org.uk/medical-connectors

Re:Thinking out of the box (4, Insightful)

couchslug (175151) | more than 3 years ago | (#33367614)

The Compressed Gas Association has been using incompatible, standard fittings for (many decades), along with colored gas hose where appropriate (welding torch hose is a common example).

The medical industry strikes me as a bit odd.

In the Air Force, I couldn't work on aircraft beyond 12 hours excepting emergencies because performance drops off drastically after that long a shift. (It's fun mentioning this to interns just to see the looks on their faces!)

In the Air Force, everyone working around aircraft including pilots uses a CHECKLIST because memory is acknowledged to be fallible. Memory is nice, but get caught without a job guide and it's yo' ass!

I have more faith in military aircraft maintenance than I do modern medicine...

Re:Thinking out of the box (2, Informative)

INT_QRK (1043164) | more than 3 years ago | (#33367656)

All of which highlights the importance of safety engineering and the Human Systems Interface, especially for life-critical systems. Here's a decent synopsis on the field: http://en.wikipedia.org/wiki/Safety_engineering [wikipedia.org]

labels? (0)

Anonymous Coward | more than 3 years ago | (#33367322)

No?

 

Well... (0)

Anonymous Coward | more than 3 years ago | (#33367338)

On the other side of the coin...

I could see such a system leading to patient deaths because of their complicated color system. If a locking head needs to attach to a patient line now, i'm sure that comparing colors could add unneeded time to compare and contrast a color scheme.

I guess the real question is: What do nurses think?

“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.”

At least one nurse from TFA agrees that there is a problem to be solved. Who would know better than someone in the trenches?

Re:Well... (1)

DarkKnightRadick (268025) | more than 3 years ago | (#33367382)

And since the industry won't take care of it, I agree the government needs to step in and make them take care of it, though I'm not sure if permanent regulation (temporary until it's SOP should be good enough) is the answer.

Re:Well... (1)

somersault (912633) | more than 3 years ago | (#33367384)

If a locking head needs to attach to a patient line now, i'm sure that comparing colors could add unneeded time to compare and contrast a color scheme.

If by locking head you just mean something to cap the tube, I doubt that would matter so much. Besides, you could just put your thumb over the top until you find the right colour - seriously, how long does it take your brain to match 2 colours together? I bet I could find an object of matching colour much faster than I could find an object of matching shape or size.

Re:Well... (1)

tibit (1762298) | more than 3 years ago | (#33367512)

The interconnect keying can be designed to allow master keys. So that a cap will attach and lock to any tube, but when mating tube ends and to other tubes or tube-attached equipment, only the like kind will mate.

Re:Well... (3, Interesting)

MichaelSmith (789609) | more than 3 years ago | (#33367642)

If a locking head needs to attach to a patient line now, i'm sure that comparing colors could add unneeded time to compare and contrast a color scheme.

If by locking head you just mean something to cap the tube, I doubt that would matter so much. Besides, you could just put your thumb over the top until you find the right colour - seriously, how long does it take your brain to match 2 colours together? I bet I could find an object of matching colour much faster than I could find an object of matching shape or size.

Funny you should ask. In the apollo program astronauts in the lunar module had a horrible mess of hoses and fittings to deal with. The rule they all memorised was red to red, blue to blue and you can see that repeated many times in the ALSJ [nasa.gov] . Its how they matched fittings to hoses.

In the case of medicine I would suggest they stick to primary colors for a set of basic properties (liquid, gas, etc) and back the code up with a pattern (say: red gets a straight white stripe; blue gets a zig zag red stripe, and so on) for lighting conditions where colours are hard to make out.

They could back that up by using different hose material for different functions. Just enough to give the hose a unique feel.

beacause (3, Insightful)

Spaham (634471) | more than 3 years ago | (#33367368)

"because the agency is so worried about making industry happy, people continue to die"

I say bullshit.
Industry would be more than happy to sell new tubes to every single hospital in the country !

Re:beacause (0)

Anonymous Coward | more than 3 years ago | (#33367450)

You're forgetting that in the US, the hospitals in many cases, ARE the industry. And tubes are expensive...

Re:beacause (1)

BubbaDave (1352535) | more than 3 years ago | (#33367476)

The for-profit hospital industry, not the medical components industry.

Dave

Color codes? Different connections? (3, Insightful)

captainpanic (1173915) | more than 3 years ago | (#33367372)

How about using color codes?
Or incompatible sizes or connections?

Damn... this is so easy to fix.

In chemical industry, and in labs, color codes have been used for the last 15 millennia or something. It's completely standard. Just a sticker or some tape at both ends of a tube, indicating it can only be used for that gas or liquid. And in the case of non-standard liquids/gases, standard labels (you know, those with text on it) are used to indicate what it's used for, and what is in it.

Re:Color codes? Different connections? (-1, Offtopic)

oodaloop (1229816) | more than 3 years ago | (#33367464)

In chemical industry, and in labs, color codes have been used for the last 15 millennia or something.

I'm sorry, what? Are you saying the chemical industry has been around for 15,000 years? Or colors have? I don't follow you.

Re:Color codes? Different connections? (1)

mcvos (645701) | more than 3 years ago | (#33367646)

Man, hyperbole is so hard to spot these days!

Re:Color codes? Different connections? (1, Insightful)

Anonymous Coward | more than 3 years ago | (#33367486)

Colour blind?

Anyway, this can't be fixed. If you use incompatible sizes or connections, you'll just hear about how nurses try to break the tubes to make them compatibles instead. When people are stressed for time, they won't be doing much thinking.

It's about education and experience.

Ummm Personal responsibility? (0)

realsilly (186931) | more than 3 years ago | (#33367378)

Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard? If you're a nurse at a station and you want to ensure that you have the correct tubes. Take a moment and label them yourselves if you are that busy.

Another poster stated that maybe color coding tubes would help, and I think this is a good idea, if the dyes don't cause problems in the tubing. My greater concern is that we have busy nurses asked to perform a lot of tasks and they usually get nothing but grief from patients, so they just want to get in get out and move on to the next person. Personally I've watched nurses double check tubelines and it takes all of 2 seconds. They are also tend to be the nurses who've been a nurse for more than a couple years.

Re:Ummm Personal responsibility? (0, Troll)

Freddybear (1805256) | more than 3 years ago | (#33367448)

It's much easier to blame "industry" and call for more costly government regulation than it is to check both ends of a piece of plastic tubing?

Re:Ummm Personal responsibility? (4, Interesting)

paiute (550198) | more than 3 years ago | (#33367452)

Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard? If you're a nurse at a station and you want to ensure that you have the correct tubes. Take a moment and label them yourselves if you are that busy.

Another poster stated that maybe color coding tubes would help, and I think this is a good idea, if the dyes don't cause problems in the tubing. My greater concern is that we have busy nurses asked to perform a lot of tasks and they usually get nothing but grief from patients, so they just want to get in get out and move on to the next person. Personally I've watched nurses double check tubelines and it takes all of 2 seconds. They are also tend to be the nurses who've been a nurse for more than a couple years.

A safety system which is ultimately dependent on a human to check it isn't reliable. Even the best nurse is going to be tired or distracted occasionally.

In contrast, compressed gases need different and nonswappable regulators so that you can't hook an oxygen tank into an acetylene line. This system is virtually idiot proof.

Re:Ummm Personal responsibility? (0)

Anonymous Coward | more than 3 years ago | (#33367726)

You clearly haven't met too many idiots.

Most of the ones I know would go "Hey bubba, this don't fit. Hand me my duct-tape."

and now instead of a tank attached to the wrong equipment you have a tank unsafely attached to the wrong equipment. Not as much of an improvment as you may think.

Re:Ummm Personal responsibility? (5, Insightful)

txoof (553270) | more than 3 years ago | (#33367466)

Personal responsibility goes a long way in every job from auto mechanic to jet pilot, but redundancies help everybody. I rather like that my radiator cap is labeled differently than my oil cap. Sure it's my responsibility to make sure I put the right fluid in the right hole, but having a little bit of labeling sure saves me some greif. I also bet that pilots enjoy having all the automated warnings built in. Sure, a pilot's job is to monitor the gauges and double and triple check that everything is working right, but when the proximity alarm goes off you can bet he's pretty happy it was there. And if you happen to be on the plane, you're probably pretty happy that it's there as well.

Nurses have hard jobs that require lots of thinking, physical labor and are frequently over worked. A little redundancy that adds minimal material cost to the appliances is not only a nice feature for them, but a nice feature for the person they're working on.

Why bother messing around with labels? (1)

Benfea (1365845) | more than 3 years ago | (#33367760)

The computer industry figured out how to make my USB plugs incompatible with my ethernet jack. More importantly, they did this without the government telling them to. They did it while operating on much narrower profit margins, and without a large number of human lives hanging in the balance.

The idiots running the health care industry should have resolved this on their own a long time ago. The government should not have had to get involved at all.

Re:Ummm Personal responsibility? (3, Insightful)

Issarlk (1429361) | more than 3 years ago | (#33367474)

So we need to make fail-proof nurses instead of making fail-proof tubes.
It's so much easier. Problem solved.

To fail is human. Even the best nurse will make mistakes after running around for 20 straight hours of work in an overcrowded, understaffed hospital.

Re:Ummm Personal responsibility? (1)

Rakshasa Taisab (244699) | more than 3 years ago | (#33367484)

Personal responsibility is a concept that seems reasonable but is basically idiotic when put into the context of the Real World. It's the same as thinking that no one will lose their job if you remove all social safety nets.

Mistakes _WILL_ happen, always, even with several layers of security protocols. That is reality and we need to design stuff with reality in mind. Just color coding or text labeling doesn't take things far enough, as those are measures that assume the nurse isn't distracted by e.g. an annoying patient that keeps complaining and demanding attention, etc, or any number of other things that can lead to fleeting moments of inattention.

The best solution here is to make it impossible to connect tubes to the wrong device. Simple, effective and takes the human out of the equation.

Re:Ummm Personal responsibility? (4, Insightful)

American AC in Paris (230456) | more than 3 years ago | (#33367490)

Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard?

"look, I -understand- your heart has stopped, sir, but if you'll just be patient with me--heh, "patient"--I'll trace these tubes back to...the...appropriate bits of--OK, that's the one..."

Personal responsibility is a wonderful thing, but nurses a) often don't have the luxury of time, and b) like other human beings, occasionally make mistakes. Further, nurses don't have the luxury of an Undo command, and very, very slight errors can and often are fatal.

...or is this some newfangled variety of personal responsibility that completely eliminates human error?

Re:Ummm Personal responsibility? (4, Insightful)

$RANDOMLUSER (804576) | more than 3 years ago | (#33367496)

That's a great idea. Rather than making a few simple changes to the interface, we'll let the Invisible Hand solve the problem. Hospitals that hire nurses who make the occasional simple, human mistake will eventually go out of business. That's brilliant. I'm so glad we have Republicans around to show us the Right Way (tm) to do things.

Re:Ummm Personal responsibility? (0, Troll)

corbettw (214229) | more than 3 years ago | (#33367696)

A government bureaucracy won't allow manufacturers or operators to make consistent changes to a product, yet it's the free market that has failed. Mr. Orwell would be so [proud|aghast] (take your pick).

Re:Ummm Personal responsibility? (2, Insightful)

Anonymous Coward | more than 3 years ago | (#33367584)

Boiling it down to personal responsibility is nice and all....until it turns out that your spouse or child is one who dies because their nurse screwed up. Sure, you can sue them, get them fired, or maybe even thrown in jail in a few rare cases, but I doubt any of that will be comforting enough to make up for your loss.

Re:Ummm Personal responsibility? (1)

TapeCutter (624760) | more than 3 years ago | (#33367594)

"Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job..."

Your the one human on this planet who has never made a stupid mistake, right?

We don't HAVE to surrender to our situations (1)

FranTaylor (164577) | more than 3 years ago | (#33367684)

Whatever has happened to personal responsibility?

Well of course, but since we humans have control over our situations and our lives, we can prepare our situations so that the risk of errors is minimized.

Example: due to a poor user interface, a pilot programs the autopilot to fly into the side of a mountain (yes this really happened). Of course it is a user error, but the designers of the autopilot STILL took the effort to redesign the user interface.

And as far as "personal responsibility" goes, well the pilot is dead, so good luck teaching them a lesson.

Re:Ummm Personal responsibility? (5, Insightful)

radtea (464814) | more than 3 years ago | (#33367786)

Whatever has happened to personal responsibility? Why is this such a problem? If a nurse is doing their job, then they will follow the tubing back to the source to ensure that they are connecting the right ones. Why is this so hard?

I'm guessing you are under 30 and/or have never worked on anything mission-critical. You've also never taken a statistics course, or if you have you have failed to apply its lessons.

It is "so hard" because nurses do this dozens of times a day to patients who change on a regular basis, and both thinking and remembering are hard. If a nurse has a 0.1% failure rate--when was the last time you got 99.9% on an exam, by the way?--they will do the wrong thing a few times a year. Most of those wrong things will be harmless. If they have a 0.001% failure rate they will still err every decade or so.

Anyone who knows anything about the actual, empirically verifiable nature of human beings, rather than some pulp fiction fantasy, knows that humans make mistakes. It is what we do. Intelligent people respond to that uncontroversial fact by building systems that make mistakes more difficult. Gibbering idiots thump their chests and witter on about personal responsibility.

Re:Ummm Personal responsibility? (1)

mcgrew (92797) | more than 3 years ago | (#33367814)

Your comment really fits your user name. You've never made a mistake? You never heard of Murphey's Law? Making these tubes all the same with the same fittings is insanely irresponsible. What about some personal responsibility from the manufacturers?

tube upgrade (0)

Anonymous Coward | more than 3 years ago | (#33367388)

you would think the industry would be behind a massive tube upgrade programme - my guess it is just the usual lazy, incompetence we see every day across all sectors.

Oh Great (0)

Anonymous Coward | more than 3 years ago | (#33367390)

It sounds to me like if these people get their way, insted of a few incidents of some idiot nurse not paying attention and hooking up the wrong tube we'll get double (or more) the amount of deaths/injuries because they won't be able to find the right tube for the connection. Brilliant! Heres a simple solution, COLORCODE THE STUPID THINGS, a couple bucks of colored electrical tape and some new procedures would solve most of the problems.

Re:Oh Great (0)

Anonymous Coward | more than 3 years ago | (#33367530)

It sounds to me like if these people get their way, insted of a few incidents of some idiot nurse not paying attention and hooking up the wrong tube we'll get double (or more) the amount of deaths/injuries because they won't be able to find the right tube for the connection.

That doesn't even make sense you fucking idiot.

Lawsuits (1)

fermion (181285) | more than 3 years ago | (#33367394)

Clearly the problem with the number of lawsuits the medical industry has to deal with is not hysterical patients, but incompetent design. Can anyone imagine,say, in an industrial setting where the water and vacuum connectors were the same. In my experience if they are they same, they are at least color coded so your eyes catches the mismatch.

Of course there is huge a cost if tubes for different purposes are incompatible with each other, not only at the vendor level, but also at the local level for acquisition and storage. And of course health care professionals will have to be trained to the point of automaticy to use the proper tubes for each purpose.

It may be that the solution is to simply hire more nurses and the like and to cut down on the overtime that lead to the mistake. Again, it will cost more on the front end for labor, but at least the lawsuits will decrease.

Poka-Yoke (3, Insightful)

amstrad (60839) | more than 3 years ago | (#33367396)

Sounds like they're in need of a Poka-Yoke [wikipedia.org] project.

Sounds like media fishing for a story (4, Insightful)

CatsupBoy (825578) | more than 3 years ago | (#33367404)

I dont mean to sound unsympathetic, but from the article:

These problems have been going on since at least the 1970s.

And:

Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups.

Hundreds of deaths in the past 40 years doesnt sound like a really big problem.

My son has spent a lot of time in hospitals, he had a broviac catheter (venous) and during his frequent and long stays this has never been a problem. As a layman it was painfully obvious which tube went where.

A much larger issue, in my mind, was actually receiving the proper meds in the proper dose.

Re:Sounds like media fishing for a story (1)

kenh (9056) | more than 3 years ago | (#33367596)

Hundreds of deaths in the past 40 years doesnt sound like a really big problem.

Exactly - this is a story becuase most readers forget how commonplace these types of medical procedures are and how many times a day they are safely carried out. How many times do mothers delivering babies NOT get spinal anesthesia in their veins? How many times do patients not get their IV lines connected to air lines? Etc...

I'm certain, if investigated when they occur, there is an aggrivating factor that contributed to the error (over-worked staff, poor working conditions, lack of training, poorly communicated instructions, someone "helping out" in an area they aren't qualified in, etc.)... True, if the tubes were differnt shapes/colors/sizes these mistakes woul dbe harder, but that buries the contributing factor (sleep deprivation, etc. that will simply cause problems elsewhere).

A good carpenter never blames his tools.

Long nursing shifts (0)

Anonymous Coward | more than 3 years ago | (#33367416)

Color coding and incompatible connectors are probably good ideas. However, there is a serious issue that probably plays into problems like this. Nurses normally work 10-12 hour shifts. There is no way you are still on you "a-game" after working for the past 11 hours. As you tire, it is easy to start making simple mistakes like these. I'm surprised this hasn't been regulated already. I understand people want long shifts so they can have more days off, but this is probably not a field that should have the option.

Re:Long nursing shifts (5, Insightful)

tibit (1762298) | more than 3 years ago | (#33367552)

It's unfortunate, but the medical industry is at odds with reality when it comes to human performance. They claim, no, swear, -- and I have first-hand anecdotes from top-notch physicians and surgeons -- that long shifts are somehow necessary for "continuity of care" and other such buzzwords. Somehow they believe they are superhumans. Nobody has ever trained them how to effectively communicate patient state to their replacements. It should be a semi-formalized process, that is being taught, and part of the licensing exam curricula. Pilots and nuclear plant operators are trained for it, why the heck doctors are nurses are above it all I don't know.

10-12 hour shifts are effed up.

Then where will nurses work? (1, Insightful)

kenh (9056) | more than 3 years ago | (#33367420)

From the excerpt above:

'Nurses should not have to work in an environment where it is even possible to make that kind of mistake,' says Nancy Pratt, a vocal advocate for changing the system.

How can an operating room be made 100% safe? Nurses go to school to learn how to work in such an environemnt. If, after years of training and working in the field they can't be relied on to know what they are doing, then what was the point of all that expensive training?

If an operating room is to be brought down to the level that anyone can assist the doctor, then nurses are irrelevant - if every pill has to be a different color, shape or size, if every tube, connection, and device needs to be a size incompatible with anything else in the room, and if all the sharp pointy tools need to have safety guards, then what have we accomplished?

Medical mistakes happen, and they always will happen, because of the humans in the process - people have bad days, make mistakes, get tired, get bad instructions, etc - but I for one, am not ready to submit myself to a CNC-style surgical machine without a human operator controling the blade, dosing me with medications from a spreadsheet, or making diagnosis via an online questionaire - I want people in the process, mistakes and all. Besides, I think the number of preventable human errors looks huge, until you realize how many times things go right - for every procedure with tens or hundred of errors per year, I suspect there are thousands or tens of thousands of similar procedures that are performed without incident - daily.

How many times do nurses manage to find the right receptical for the hoses? Gather and dose the proper medication in the proper amount? On a global scale I suspect it is on the order of billions of times a week...

Re:Then where will nurses work? (0)

Anonymous Coward | more than 3 years ago | (#33367558)

Medical mistakes happen, and they always will happen, because of the humans in the process - people have bad days, make mistakes, get tired, get bad instructions, etc - but I for one, am not ready to

do anything about it because I think the people who get killed deserved it for showing up at the hospital on a bad day with sleepy nurses misreading the charts and screwing up.

FTFY, since you blabbered on without explaining how you really felt.

Re:Then where will nurses work? (0)

Anonymous Coward | more than 3 years ago | (#33367586)

lolwut?

Re:Then where will nurses work? (5, Insightful)

Ken D (100098) | more than 3 years ago | (#33367676)

Pilots have extensive training and "know what they are doing", yet checklists are part of standard safety policies. Why? Because checklists save lives.

Does it matter if only 1 person a year dies from having a stupid mistake, if it happens to *you*, while you are having some silly routine procedure happen? Do you want to be the one who dies having an MRI because someone forgot to ask if you had any metal implants?

We could just say that malpractice judgments will incent people to do the right thing.. hey, wait...
maybe it is!

Couldn't resist (0, Flamebait)

Anonymous Coward | more than 3 years ago | (#33367424)

"killing a 16-year-old who was giving birth"

I bet that saved the state a lot in welfare payments.

Parallels with computer cabling (3, Insightful)

goodmanj (234846) | more than 3 years ago | (#33367434)

Looks like the medical community should take a page from the computing industry. Or gas stations.

In recent years, computer cables work on one basic principle: if the plug fits in the jack, it should work. Or worst case, it shouldn't blow up. Didn't used to be like this -- remember ps/2 mouse/keyboard ports?

Gas stations work the same way: it's pretty much impossible to accidentally fill a gasoline car with diesel fuel, because the diesel filler tube is too large to fit in an unleaded tank's opening. (Doesn't work the other way around, of course, but diesel users are in the minority, and can be assumed to be paying attention.

Easy enough to do this with medical tubing. Make oxygen tubing always a specific diameter, tinted a specific color, and with a special fitting on the end that only plugs into oxygen-specific devices. Same with IV tubing, different diameter, different color, different fitting.

You don't even need the FDA to take charge to make this happen. It's not like the government regulated the USB spec, after all. All you need is a consortium of major medical equipment manufacturers to get together to agree on a standard. What incentive do they have to do this? Well, once they set a standard, EVERY HOSPITAL IN THE COUNTRY needs to buy all-new tubing, plus all the devices designed to connect to that tubing. Small manufacturers can make a fortune just selling backwards compatibility adapters.

The Connector Conspiracy. It's a beautiful thing.

Re:Parallels with computer cabling (4, Insightful)

Obyron (615547) | more than 3 years ago | (#33367628)

You don't even need the FDA to take charge to make this happen. It's not like the government regulated the USB spec, after all. All you need is a consortium of major medical equipment manufacturers to get together to agree on a standard.

Except you do. If you're talking about new medical equipment, it has to be approved by the FDA. There have to be exhaustive trials with each tube, a battery of tests showing that the color tinting will not leach out of the line when exposed to any one or two of a million different medications, and clinical trials to determine the incidence of allergic reactions to the tinting dye. It would could billions of hojillions of dollars and take ten years, and what we have already works. You're fighting decades of inertia for not much statistical gain. All of this is why a pair of disposable plastic forceps costs 1000 dollars when you get your hospital bill.

Re:Parallels with computer cabling (0)

Anonymous Coward | more than 3 years ago | (#33367728)

> In recent years, computer cables work on one basic principle: if the plug fits in the jack, it should work. Or worst case, it shouldn't blow up. Didn't used to be like this -- remember ps/2 mouse/keyboard ports?

You obviously never worked with the Amiga. Commodore put +5vDC on an RS-232 connector. It was in support of their brain-damaged daisy-chain external devices. Inherited from the C64 were they? Also, I remember losing a TRS-80 to a moron who plugged the power supply into the tape I/O port.

"... if the plug fits in the jack, it should work." I'm guessing you work at "Chester's 'puter 'pair", just over there, turn left on the dirt road...

what the bleep are you talking about? (1)

FranTaylor (164577) | more than 3 years ago | (#33367756)

dude have you never swapped the ps2 keyboard and mouse cables and wondered why neither works?

interesting how that rj-11 phone plug goes right into the ethernet jack. I wonder what happens when the phone rings?

why on earth do i need a sata/e-sata adapter?

please make a list of all the USB connectors and their purpose

go on find a new power supply for your external drive enclosure

the computing industry is VERY POOR at good connector design

Re:Parallels with computer cabling (1)

tomhudson (43916) | more than 3 years ago | (#33367774)

it's pretty much impossible to accidentally fill a gasoline car with diesel fuel, because the diesel filler tube is too large to fit in an unleaded tank's opening.

True story:

"I just put half a tank of diesel in the car. What should I do?"
Me: "Fill it right to the top with gasoline, then drive. Wnen you've used up a couple of gallons, top it off again. Repeat every day."
"Will that work?"
Me: "You better hope so! It's 20 below!"

So yes, people can fill their gas tanks with diesel. And yes, it worked. #1 diesel (winter months uses a thinner grade to prevent wax build-up) is lighter than #2 diesel. The exhaust smelled like an old bus, but it worked.

It makes sense (1)

kannibal_klown (531544) | more than 3 years ago | (#33367438)

Having all of the tubes be plain transparent plastic does present an issue. It's not a huge deal when a person just has one tube, such as an IV drip, but multiple tubes can get confusing. Think of the rat's nest of power plugs behind your computer desk or entertainment center, especially if all of the power cords are the same color 3-prong connections.

My first thought it to have pale shades of color for the different kinds of tubes. However that presents a problem because the color of a tube might obscure the compound a little since it's not as transparent. Plus there are only so many colors they could use without dealing with color-blindness or some other near-color issue (is this blue or purple). And lastly, since there are only so many colors they can use, then confusion can still occur and be worse if you're dealing with a pink fluid going through a pink tube... which is which.

The other thing I can think of is different kinds of connections/slots. However then you have an over-engineered tube instead of a plain cylinder-into-cylinder tube which is easier to maintain and doesn't need replacing as much.

So it's not a no-brainer fix, since the fixes themselves aren't perfect and introduce other issues.Though I agree, something more should be done since during emergency or stressful times even an experienced nurse can make a mistake if there are enough tubes around.

Re:It makes sense (1)

goodmanj (234846) | more than 3 years ago | (#33367666)

In my opinion, "over-engineering" isn't a problem where medical devices are concerned. With a price of $5-10 dollars for a couple of grams of plastic, manufactured by the millions, the profit margin on these makes aftermarket USB cable vendors look like chumps.

You can afford to spend a little extra money making a square or hexagonal fitting, a threaded connector with a particular diameter and thread gauge, etc.

If your IV tubing ends up costing a little more than your competitors, no problem. Just ask your customers how the money they save going with your competitor compares with the price of a malpractice settlement.

Re:It makes sense (1)

goodmanj (234846) | more than 3 years ago | (#33367714)

OK, I take that back. It *is* possible to over-engineer medical devices. See this post [slashdot.org] .

If filling stations can do it... (2, Insightful)

AlecC (512609) | more than 3 years ago | (#33367444)

All places I fill up my car have colour coded hoses for lead-free petrol and diesel. Computers are colour coding sockets. Simple, and pretty fault tolerant (though remeber the colour blind).

And don't think it will fix everything. On an aircraft, a non-return valve in a fuel line had different threads on the two sides so that it could not be installed wrong - supposedly, Until some idiots get out the taps and retaps the socket to take it backwards, resulting in a crash. But it seems to be a cheap mechanism for a 98% solution, just requiring someone to take the lead.

LEAN Manufacturing Principles (1)

Pilon (142247) | more than 3 years ago | (#33367470)

It's called Poka-yoke from the Lean manufacturing world: http://en.wikipedia.org/wiki/Poka-yoke

Just this Week (0)

Anonymous Coward | more than 3 years ago | (#33367482)

Just this week - news in Sydney, chlorhexidine as an epidural, shudder the thought >.
http://www.smh.com.au/nsw/how-could-this-happen-hospital-blunder-turns-a-familys-joy-into-heartbreak-20100820-138xw.html
Human error it seems, not following correct procedure - and yeah, she's fucked up.

Murphy's law (0)

Anonymous Coward | more than 3 years ago | (#33367508)

This is the definition of Murphy's law, right?

RFID (1, Insightful)

Joebert (946227) | more than 3 years ago | (#33367514)

Make clips with RFID tags in them, and labels on them, which clip on to the tubes as soon as they're inserted into a patient. Put sensors in the things the tubes connect to, any time one of the RFID tags gets close enough to something it wasn't intended to be connected to, sound an alarm.

Re:RFID (2, Funny)

goodmanj (234846) | more than 3 years ago | (#33367704)

Okay, so I said in an earlier comment [slashdot.org] that there's no such thing as over-engineering things when medical devices are concerned.

You just proved me wrong.

Re:RFID (1)

jeff4747 (256583) | more than 3 years ago | (#33367738)

Because when a patient has many tubes coming out of them, those tubes won't be in close proximity and constantly sounding the alarm.

Re:RFID (1)

Dunbal (464142) | more than 3 years ago | (#33367784)

An alarm that sounds all the time is completely useless and in itself can do more harm than good. Ask the ghosts of these [portaldeartes.com] pilots.

Pun potential detected (2, Funny)

dark_panda (177006) | more than 3 years ago | (#33367572)

Hmmm I wonder if this Dr. Robert Smith fellow has... The Cure... to such problems...?

A good book that speaks to this (0)

Anonymous Coward | more than 3 years ago | (#33367608)

Here is a very good book that covers many of the same issues. The human factor: revolutionizing the way people live with technology By Kim J. Vicente

Checking Out STAT (0)

Anonymous Coward | more than 3 years ago | (#33367632)

At one hospital I know, a nurse gave a patient kaopectate intravenously.

In a bit of foot-in-mouth disease only I am capable of, one night I told this story at a party only to discover later that the hospital admin who'd been in charge at the time was one of my listeners.

Rural? Be afraid, be very afraid (1)

Ultimate Heretic (1058480) | more than 3 years ago | (#33367634)

As a sibling of a couple of physicians, I get to hear a lot about the quality of personnel in small and rural hospitals. In general, the advice I have been given is that unless I am about to expire, I am to head for the nearest large city and a hospital therein. Why? The spectrum of support staff at smaller, more isolated hospitals tends to the lower end in skill. It is unfortunate intersection of cost (cannot pay as well in small cities/hospitals) and availability of better trained staff. As an outsider, I see this as partly due to the increase of turning many formally well trained support positions into ones held by what the human resources want to term as 'technicians'. Nothing wrong with being a tech, but the push is for the lowest training and therefore lowest cost. After all, the machine cannot make a mistake and anyone can hook up the tube/insert the sample/draw the blood/distribute the medicine, etc. However, complete ignorance of the meaning of test results/medical weights an measures/meaning of standards, etc. leads to some funny results (deadly, not ha ha). In essence, if you or an advocate (family or friends) are not on duty 24/7, you can be at the mercy of mistakes through ignorance, negligence or simply chance. YMMV.

Is the alternative better then? (1)

Errol backfiring (1280012) | more than 3 years ago | (#33367648)

If you have to have a zillion different tubes at hand and also of different lengths, you are bound to be out of one of the necessary ones each time. Now this can be life-threatening. Also, the time it takes to search for each of them could easily kill a few patients as well.

Really? (1)

kenh (9056) | more than 3 years ago | (#33367654)

'FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,' says Dr. Robert Smith.

Yeah, right - the FDA is simply a rubber-stamp for the mdical industry... You have to be painfully ignorant of the medical field to make such statement.

We really want the FDA to regulate the size, color, and style of connecotrs on all medical devices? Seriously? We can't trust doctors with surgical tubing any more?

That sounds expensive, especially when you factor in the cost of all the CYA expenses to protect hospitals/medical providers from federal fines and penalties...

ha hah hahha ahaa hhha ha ha haahhaa (1)

Jodka (520060) | more than 3 years ago | (#33367664)

'FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,' says Dr. Robert Smith."

As someone who works in the medical device industry, let me say, that statement is preposterous. The FDA is not worried about "making the industry happy." First, to the extent that FDA has a bias, it is staffed with anti-corporate zealots who believe that making a profit from the sick and dying is unethical and are out to make the industry unhappy. Secondly, there is no reason whatsoever that this initiative has to come from the government. Just like 802.11, firewire, bluetooth and every POSIX did not come from a government agency, neither would a tubing standard. Third, selling specialized tubing products to hospitals would be more, not less profitable than commodity tubing products. Fourth, if the industry did create a standard, the barriers to developing and deploying that would be the FDA. Rule of thumb is that the cost of bringing a product to market is about 10X under FDA regulation than not and delays in FDA approval can be several years.

From the manufacturing side (0)

Anonymous Coward | more than 3 years ago | (#33367706)

I work on the manufacturing end of the medical devices industry. It would take a massive change to alter this. Most of the parts we make are interconnect-able by design, so that individual valves, fittings, and devices can be assembled into the set that is needed. These systems are not as pre-engineered as everyone thinks they are. Some sets are standard, but many are custom made according to the hospital's requirements. And these are still just components of a larger system assembled on-site. Most tubing sets are terminated with a luer-taper (wikipedia) [wikipedia.org] connection (the standard connection on the end of a syringe - not the needle). This allows interconnection with other devices. Even if you were to change the end connections, a side port with a luer taper connection would always be required by hospitals so that a syringe could be used to access the line. Color coding could possibly help. The best solution would be to leave the sets as-is and at the hospital tag each with an obvious colored label as it is installed/assembled.

Compared to the computer industry (1)

picoboy (1868294) | more than 3 years ago | (#33367712)

At some point these medical manufacturers need to organize themselves into standards bodies or else the government will do it for them. Perhaps the problem is that the medical equipment manufacturers don't have the same cultural view that their counterparts in the computer industry have (Apple excluded, of course) that standards are beneficial to their business. I'm not exactly sure why this is, perhaps others closer to the medical equipment industry have better insight. But I suspect that it isn't as easy to fix as many of us slashdotters (read computer geeks) dismissively suggest because it is more dependent on culture and politics, not technology.

It's society's fault! (1)

Dunbal (464142) | more than 3 years ago | (#33367732)

Nurses should not have to work in an environment where it is even possible to make that kind of mistake

      Speaking as a physician, it's your responsibility to know exactly what you're doing. Blaming "the environment" is just making excuses for gross negligence. Just like it's wise to double-check the medication you are dispensing, double-check the dose you are administering if it's a substance with dangerous side effects, and screen your patients before surgery (instead of doing it the way we used to pre 1980's, when a significant number of patients died on the table because they had unknown underlying conditions we would find out about in the autopsy), you should make sure that you're performing a procedure correctly. If you don't do that, I suggest another line of work.

OMFW (1)

hesaigo999ca (786966) | more than 3 years ago | (#33367806)

>Nurses should not have to work in an environment where it is even possible to make that kind of mistake,'
>FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die

Ok first off, if I am a nurse and know that there are too many tubes, just like when you are a network admin and have to run cable along, they are not going to make all sorts of different cables for you, YOU have to sort them out, usually with permanent marker or with color tape etc...etc... so if you know some nitwit is working for you not able to first off check which line she is working with by actually making sure where each end meets what.....then you could color code the tubes yellow means blood, green means iv, blue means etc...etc..

Seriously, let's put all the onus on others instead of ourselves, that is so much easier. Instead of owning up to your own mistake, you would think the first death related to this, the nurses would go to the office supply store and buy those stickers and stick them on ALL the tubes to sort them out...

As for the FDA being in someone's pocket, guess what your own President is in someone's pocket, and yet you still vote for them,
we still put up with the media cover up for what BP did, when was the last time we heard anything about THE BIGGEST OIL SPILL IN HISTORY, if I was Obama, I would be talking about this everyday for the next 4 years. Yet he is bought off, the media is bought off....my point is we can only rely on ourselves....so for this situation, the nurses need to just accept the FDA are turds, and they need to step up, and come up with their own system, after all THE NURSES are the ones giving the care, and liable not some tubing company.

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