Tubing mix-ups, the FDA, and serious harm to patients - page 3

by TDCHIM | 5,564 Views | 26 Comments

This story infuriated me: I cannot get rid of the mental image of that poor woman with the food-blood sludge in her veins. Yes, it is difficult to get multiple device manufacturers on the same page, but that's one of the... Read More


  1. 0
    Quote from grannyNan
    I just worked with an defense attorney on a case similar to this, and yes you can attache IV tubing to a feeding tube and vice versa. The case which I worked on was a nurse who used the Abbott Plum pump to administer a tube feeding. It was the hospital's policy to use the IV pump because they did not want to buy feeding pumps!!! It cost a man his life and ruined a potentially good nurse. All in the name of saving some money. The FDA should never allow an IV pump to be marketed as a feeding pump. All tubing should have some sort of difference to it so as to make it EXTREMELY difficult to interchange. Nothing is foolproof, as someone out there in always smarter than the tubing. As for the miststake being acceptalbe or unacceptable, unless you can walk on water and honestly say you have never made a mistake be it big or small we as a group of nurses should not point fingers at one another.

    Well I don't know any nurses who have never made a mistake myself included. I have taken care of 8 and 9 patients at a time, trachs, vents etc... all on tube feeds and STILL in 25 years have never attached a feeding tube to an IV site. I don't walk on water, I just pay attention.
  2. 1
    This is usually a cognitive error and unintentional- when we have familiar task that we do constantly we form pathways in our brain and we do the task effortlessly . This is like locking the keys in the car - you know better - you may always check but once and awhile you will "slip".
    We have to accept imperfect human performance and gaurd against it by safer design.
    and stop blaming nurses for being human - the real sad part is not changing something we can
    - and not protecting patients
    - and destroying nurses who are trying to do the best job they can for patients
    Debora

    Tubing Misconnections - A Systems Failure With Human Factors: Lessons for Nursing Practice
    Debora Simmons, MSN, RN, CCRN, CCNS; Krisanne Graves, BSN, RN, CPHQ
    Log In Problems
    grannyNan likes this.
  3. 0
    Actaully it is impossible to say there are more or less- we dont have good error reporting sytems
  4. 0
    Actually it is impossible to say there are more or less- we dont have good error reporting sytems
  5. 0
    What if the feeding came in a bag that looked like an IV bag?
  6. 0
    Quote from itsmejuli
    Had a resident who was receiving Jevity via foley type G-tube. He also had a supra pubic foley catheter. Apparently, before I started working there, a nurse had plugged his feeding tube into his supra pubic cath and his bladder was filled with Jevity. He survived, she was fired.

    I can't imagine what she was thinking she was doing.
    I cant imagine firing the nurse helped anything or anyone
  7. 2
    I ran across a good example of this on an agency assignment at the level II NICU of a community hospital the other day. This hospital uses the same type of syringe pump, the same syringes and the same type of clear tubing for all syringe infusions (gavage feeds, IV bolus meds, IV syringe drips).

    One of my patients was a growing preemie on TPN, intralipids, and gavage feeds. The TPN was infusing with an IV pump that couldn't possibly be confused with an enteral pump, so we were good there. However, hooked on that same IV pole there were two syringe pumps. One was infusing intralipids into the IV with TPN. The other was infusing breast milk into the NG tube.

    Essentially, we had a white liquid going from a multipurpose syringe pump through clear tubing that was connected to a blue/greenish gavage tube. Just below that was a white liquid going from an identical multipurpose syringe pump through clear tubing (Y-connected to TPN tubing) that connected to a blue/greenish IV T-connector. All of that was infusing into a <2 kg baby who was snugly nested inside an enclosed isolette. Disaster waiting to happen.

    We should check and double check, label lines, keep things organized. But as the mounting list of tragic stories continues to show, people do make incredibly dumb mistakes. If we can keep those mistakes from ending or permanently altering a life, I'm all for it.
    AtomicWoman and grannyNan like this.


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