Hospitals often rely on plastic tubes to provide patients medicine, nutrition or oxygen. But because much of the tubing looks the same and is interchangeable, mix-ups commonly occur that, researchers say, have led to hundreds of serious injuries or deaths, The New York Times reports.
“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.”
The Times story highlighted the case of a woman who died after a mix-up in which a feeding tube that was supposed to carry nutrition to her stomach was instead directed into one of her veins — a mistake that, the newspaper said, was “like pouring concrete down a drain.”
In other cases, intravenous fluids have been connected to tubes that were supposed to deliver oxygen, causing suffocation.
The precise toll in injuries and deaths is unknown, because these types of hospital mistakes rarely are reported.
Some companies have used color coding to distinguish between different types of tubes, but they often use different systems, perpetuating confusion.
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.
