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

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... Read More

  1. by   EricJRN
    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.