Friday, August 22, 2014

Hospital Tube-Connection Mishaps...More Than a Mere "Oops..."

"The tube just came out. These things happen."

I'm sure thousands of families have been told this in hospitals when any sort of tube, catheter, or other medical device lost its connection with a patient.

A recent report, however, shows that this is frequently not something that "just happens." Rather, it appears to be a problem that is both underreported and largely preventable. According to The Joint Commission, which sets standards for accrediting hospitals, tube misconnections can have devastating consequences:

The New York Times reported on the death of a fetus and expectant mother after
a feeding tube was accidentally connected into the mother’s bloodstream. 6  In 34
various publications, 116 other case studies were found involving misconnections
directing enteral feeding solutions into IV lines. 7  These adverse events resulted in
21 deaths. It is believed that tubing misconnections are underreported; adverse
events related to tubing misconnections are sometimes not reported, especially
when the mistake does not result in harm to the patient, 1  and they are sometimes
reported under another category, such as a medication error. The risk for tubing
misconnection is high, considering that almost all patients admitted to the hospital
are likely to receive an IV. 8  This risk is also seen in other settings.   

Types of misconnections that have been reported to cause serious injury or death or the potential for both include:

  • Feeding tubes connected to IV's;  
  • Limb cuff inflation devices connected to IV's;
  • Epidural solutions connected to  Peripheral or central IV catheters;   
  • Epidural line connected to IV infusions;  
  • Bladder irrigation solution using primary IV tubing connected to  peripheral or central IV catheters;  
  • IV infusions connected to indwelling bladder or "foley"catheters;   
  • IV infusions connected to nasogastric (NG) tubes;   
  • Primary IV tube connected to blood products;  
  • Feeding tubes connected to a tracheostomy tube; or  
  • IV solutions administered via blood administration 

Why do so many tube misadventures occur in hospitals? Two major reasons include (1) health care providers going into "automatic" mode (I prefer to call it "auto pilot" syndrome) due to stress or fatigue, and (2) "spaghetti syndrome"---too many tubes and wires strewn in haphazard fashion. Both are the proverbial "accident waiting to happen."

As you can see, many of these causes are entirely preventable, which is why The ISO (International  Standardization Organization) is formulating new standards that will hopefully spurn hospitals to take measures to prevent tube misconnections from occurring.

Having litigated two misconnection cases, both resulting in death, I can attest to how easily they can be prevented, and how awful they were for a family to accept. Although from the list above some of these tubes and wires have fancy names, most all have one thing in common: they are frequently a loved one's lifeline. You don't need to be an Ivy League trained doctor to know that if you knock out a patient's lifeline, some really bad things can happen...