If you have to be hospitalized chances are reasonably high that at least one tube will soon be sticking out of your body. We’re thinking, “Does it have the right stuff in it?” “Is it the right strength?” “The right flow rate?” Few of us probably fret about whether the appropriate tube was being threaded into the right place.
Turns out that’s what we should be worrying about.
Gardiner Harris contributed a terrifying story to the New York Times about tube mix-ups in hospitals.
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.
Nurse Thao had worked two consecutive shifts the previous day, and exhaustion could have played a role. But the problem is more straightforward. Tubes for different functions should be made incompatible—but they aren’t, leading to many documented mix-ups (and many more suspected as this kind of error rarely gets reported).
Harris notes that groups have tried to fix the problem for more than 15 years, but guess what stands in the way? You guessed it—the companies that make medical devices. Making changes to protect patients would be difficult—and costly. It would require cooperation among companies. Red tape and drawn-out FDA procedures don’t help any.
A color coding scheme seems like a good short term answer, but it turns out that different companies use different colors that can make things even more confusing.
In the meantime, it probably wouldn’t hurt to ask the staffer to carefully explain those tubes before they get stuck into your innards.