Healthcare News & Insights

Look-alike tubes kill patients regularly: Why is this still allowed?

Mistakes as simple — and avoidable — as confusing an IV with a feeding tube regularly injure and kill patients. And industry interests seem content to allow it to continue.

Unlike other safety-critical industries like aviation and nuclear power insist on having multiple precautions and fail-safes in place to ensure that workers can’t commit a fatal error over a momentary lapse such as hitting the wrong button.

But nurses and other health care providers have no such safety net when it comes to the tangle of tubes that may be hooked up to a typical patient. Rather than use color-coded tubing or incompatible hook-ups, most of the tubes used for blood, medication, food, etc. are identical.

That makes it all too easy for a nurse or other health care provider to accidentally grab the wrong line and push liquid nutrition into a vein or IV fluids into tubes meant to deliver oxygen.

Several hundred such errors are known to have lead to patients’ death (and many more caused severe injuries in patients who survived). Experts believe that due to under-reporting the actual numbers of patients affected are much higher. A 2006 survey found that 16% of all hospitals had experienced at least one feeding-tube-related error.

Why does this problem persist? Most experts blame lax oversight by the FDA and successful efforts by manufacturer organizations to slow efforts to create more stringent standards.

One basic move would be to make feeding tubes incompatible with tubes meant for the skin or veins. The FDA is currently reviewing that plan as well as related suggestions to make the tubing safer for both patients and their caregivers.

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