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

  1. 2 This story infuriated me:

    http://www.nytimes.com/2010/08/21/he...s.html?_r=1&hp

    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 reasons why we have the FDA. If this has been a recognized problem since the mid-90s, it seems to me that the issue could have been dealt with by now. But the device manufacturers have the money, so instead we get delays and finger-pointing.

    Perhaps I'm expecting too much or not seeing the big picture. Thoughts?
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  3. Visit  TDCHIM profile page

    About TDCHIM

    From 'Ohio'; 38 Years Old; Joined Apr '10; Posts: 721; Likes: 1,115.

    26 Comments so far...

  4. Visit  azhiker96 profile page
    3
    I bet the problem extends further back than the 90s. Specialized connections might help but this type of thing will continue as long as there are people who don't see a problem with IV administration of Jevity.
  5. Visit  latebloomer74 profile page
    0
    I'm not sure I understand the problem with the tubes. Isn't there a doctor's order stating that this is a "liquid food" and should be adminstered with an NG tube? Can someone explain it to me?
  6. Visit  Mommy&RN profile page
    2
    I have seen an RN attempt to prime IV tubing with tube feed, and she asked why it wasn't priming properly. Thankfully she asked!

    Our tube feeding tubes are very different from our IV tubing, but with enough persistance, the feeding could have been primed in IV tubing.

    Our epidural tubing is bright yellow and only initiated or changed by the ansthesia team.
    Michigan and cherryames1949 like this.
  7. Visit  cherryames1949 profile page
    6
    This all boils down to money. The FDA is pandering to the politicians and the drug / medical supply companies. It would seem to be an easy fix but the supply companies will spend millions fighting reform. It always baffles me. If we can make something safer or foolproof why don't we? Mistakes will happen as long as people are working 16 hours a day.
    KeyMaster, luvinursing, MsbossyRN, and 3 others like this.
  8. Visit  EricJRN profile page
    5
    Quote from studentkk
    I'm not sure I understand the problem with the tubes. Isn't there a doctor's order stating that this is a "liquid food" and should be adminstered with an NG tube? Can someone explain it to me?
    The beginning of the article made it sound like the nurse thought that the feed was supposed to go by IV. I'm surprised by that.

    Here is usually what happens:

    The nurse is actually familiar with the feeding route, probably having done it hundreds of times before. Who really knows why - maybe it's a bad day, poor staffing, a moment of egregious oversight - but the nurse inadvertently connects the feeding to a port/medication line on the IV tubing - thinking that they have correctly connected it to the patient's NG tube. The nurse starts the feed, then walks away. The pump may not ever alarm because there may be no actual problem with the flow of the feed.

    The point of the article is that there is a way to approach these errors at the system level. Rather than taking the chance that each individual nurse will get it right, why not make tubing that is a different color, with distinct labeling and a tip that physically does not fit on an IV port? The two units where I have worked full-time both used this solution, but the article says that some companies want to make the new tubing and have had issues with the FDA approval process.
  9. Visit  iluvivt profile page
    14
    Tubing misconnections have been happening for decades and there have been many FDA alerts. I have read about many of these occurrences in my IV Therapy publications. I have a policy that I NEVER deviate from and I mean NEVER. Anytime I connect anything or check any IV line or any tube or line that another has set up...I trace the entire line from its starting point to its end point on the pts body. So in the case of an IV bag....I check the RX (does it make sense..does the name match the pts))..I check the pump....(the setting..is it working properly)....I follow the line down (if it is entwined...I fix it)..keep going to see the VAD site (check that for any complications..date etc). This article points out how devastating it can be to give something into the vascular system that is not intended to go there.There have also been deaths from O2 tubing being hooked up to IV lines (YES it fits with a little work) There also has been many deaths when Chemotherapy was given intrathecally and was supposed to be given intravenously I do the same thing for any line or tube. It really take just a bit of time and I found a lot of errors this way. I learned very early how easy it is to do this especially when you are busy. One of the most distracting things can be the constant interruption a nurse faces.......never let this get you frazzled and disorganized. I also learned this lesson early as I saw how easy it was to do harm when you are really stressed...so it can be completely chaotic and I can stay calm . I can not help but think how busy and stressful nursing can be and how overworked we are most of the time YET all the studies show that more nursing hours means less mistakes and less deaths.........when will they all get the picture. In the meantime nurses have to be so careful even it is something they can do in their sleep. They need to develop their own strategies for prevention until things change
    Jarnaes, RNLaborNurse4U, leslie :-D, and 11 others like this.
  10. Visit  Rnandsoccermom profile page
    3
    I'm sorry but I don't understand this mistake at all.

    First off, any prudent nurse would have asked for an order to put down an NG for the TF, or at least clarified how this was to be administered.

    Secondly, for 25 years wherever I have worked the IV tubing AND IV pumps do not in any way shape or form resemble each other, including how they each connect to the patient. It physically isn't possible to plug the TF into an IV line particularly now with the needle-less systems.

    I don't care how busy you are, this IS NOT the type of mistake I find acceptable and the FDA is not responsible for this.
    luvinursing, chloecatrn, and azhiker96 like this.
  11. Visit  latebloomer74 profile page
    0
    Quote from EricJRN
    The beginning of the article made it sound like the nurse thought that the feed was supposed to go by IV. I'm surprised by that.

    Here is usually what happens:

    The nurse is actually familiar with the feeding route, probably having done it hundreds of times before. Who really knows why - maybe it's a bad day, poor staffing, a moment of egregious oversight - but the nurse inadvertently connects the feeding to a port/medication line on the IV tubing - thinking that they have correctly connected it to the patient's NG tube. The nurse starts the feed, then walks away. The pump may not ever alarm because there may be no actual problem with the flow of the feed.

    The point of the article is that there is a way to approach these errors at the system level. Rather than taking the chance that each individual nurse will get it right, why not make tubing that is a different color, with distinct labeling and a tip that physically does not fit on an IV port? The two units where I have worked full-time both used this solution, but the article says that some companies want to make the new tubing and have had issues with the FDA approval process.
    Thanks for the explanation. I get it now
  12. Visit  mskate profile page
    13
    I had a new grad just coming off orientation working with me. We had a "buddy" system for new grads to be paired with an experienced nurse when they were off orientation - the new grad could feel comfortable asking the experienced nurse questions and the experienced nurses were supposed to keep an eye out while they got their sea legs in the ICU.

    I was paired with a nurse I will call "Jenny". Jenny walked into the pod we shared holding a 60cc luer lock syringe filled with a bright orange substance. I was curious because I had never seen a med look quite like that, I asked what it was, she said "Orange Juice. My patient's blood sugar is low." So I looked into her patients room and her patient one our chronic trach/peg people. I thought I was being helpful when I reminded her that the luer lock syringes won't attach to the patient's peg tube and she would need a syringe tip 60cc.

    She looks at me like I've said the silliest thing on the planet and said "Well, I know that. It's not for her peg tube. Her sugar is really low, so I'm giving it IV."

    You could have knocked me over with a feather! I said "You are planning on giving orange juice IV to someone?? You can't do that!!!! You will kill her!"

    and I am not even kidding ----- the looked me square in the face, exasperated at me and says "It will not!! I talked to the dietary people and made sure I got the pulp free kind!" .....

    Oh, its the PULP that causes the problems. I see... Of course, I stopped her and explained everything - but oh my goodness! You can't make this stuff up people! haha Sometimes horrible route/substance errors are not just someone being absent minded - sometimes people REALLY DON'T GET IT!
  13. Visit  ayla2004 profile page
    0
    I will say my hospital has changed it PEG to avoid this(have bladder syringe tip), syringes for enteral use have purple barrels as a UK safety measure
  14. Visit  AtomicWoman profile page
    4
    Quote from mskate
    and I am not even kidding ----- the looked me square in the face, exasperated at me and says "It will not!! I talked to the dietary people and made sure I got the pulp free kind!" .....
    I am very frightened all of a sudden...
    Hygiene Queen, Jarnaes, WalkieTalkie, and 1 other like this.
  15. Visit  Indy profile page
    1
    Hmph. I read the article and I have to say, there are less of these tubing problems now than five years ago, from my standpoint. Maybe I'm working for good facilities that see the point of this.

    On my first nursing job you could have connected a BP cuff to an IV line if you tried. Thankfully, no one did, and my job now has a system that just won't do that. It looks similar, but the size is off. (yes, I checked.)

    We use Kangaroo brand tube feed pumps and the ending on the tubing for them, is this bright purple, large conical doohickey that doesn't fit to anything. Like, it's hard enough to get that thing to go in a PEG tube where it belongs, you ain't gonna hook it anywhere else. Ok so since it's shaped like a xmas tree you could hook it to a nasal cannula... but I think all that would do is make tube feed run down the patient's face. Tubefed patients are sat up and usually trached so even if it got in their mouth the trach cuff would stop it, I think. The vent tubing is an inch in diameter and no, you ain't hooking tube feed to that. I am also pretty sure you can't hook a luer lock to a nasal cannula without some foam tape and possibly rubber cement.

    Our IV systems are luer lock. Now my second job was needleless and I liked the system, however they went to luer lock in order to use the silver-impregnated end caps for IV systems.

    Where I work now the 60cc cath tip syringes are everywhere as far as stocking them. You find them in every station and central supply. The 60cc luer locks are not. They are in one place and in a different container. And god help me if I find someone trying to commit any of these errors. (Not accidental, tired, just "hey this orange juice is clear so it can go IV right?")
    cherryames1949 likes this.


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