Wednesday, 27 June 2007

In Passing

Bring in the engineers

Laura Landro's "Informed Patient" column in today's Wall Street Journal[no link, I read the hard copy] is all about "crossed-tube" connection errors, and how hospitals are scrambling to do something about them.

...the risk that someone will inadvertently hook the wrong line to the wrong device or medication is a nightmate scenario: An air hose accidentally connected to an intravenous line can create an air bubble that leads to a fatal embolism, or an infant's feeding solution inadvertently infused into the bloodstream... can cause severe brain damage and death.
Further into the article, there's this shocker:
The main concern... is the use of a universal connection system known as a Luer fitting... to join together a broad range of devices with totally different functions... Patients are at risk, for example, if they are receiving fluids through a vein, feedings via a stomach tube, and getting air through an oxygen mask. 'Nearly all tubings have the same connection...'" [bolding mine - o.g.]
The hospital's situation is analogous to what you'd face at home if manufacturers used the same two-blade connector to hook up your table lamp, your ethernet cable, your telephone, your stereo speakers, and your air conditioner. Recipe for disaster, or at least for releasing lots of magic smoke.

It appears the medical-care industry has been slow to take action for the "usual" reasons:  Denial+convenience+ cheap+ "we've always done it that way"+ bureaucracy.  Doctors and nurses are trained to check and re-check ("we don't make mistakes"), the Luer fitting is common and readily available (so it was  convenient to use it in new applications), bean-counters don't like having a lot of different inventory items to track, and suppliers have been reluctant to rock the boat by producing products that don't match with existing items. Then there's the usual problem of getting federal ("even if you want to do something, you still have to get it past the feds first") approval.


And it's discouraging that the Food & Drug Administration, which one would think would be urging action, has opted for... "education."
The FDA, which says Luer misconnections reamin a significant public health issue, recently asked the Beaumont Tachnology Usability Center... to devlop education tools to help hospitals deal with misconnection issues and make staffers aware of their impact on patient safety.
Gee, now that they're making everyone "aware," I feel SO MUCH SAFER.

Engineers know how to handle connection issues, in fact it's a natural part of good design:  If "device A" should never be connected to "circuit B," then you don't use the same damn connector on both of them

The FDA can futz around with education if it wants to, but someone-- either in the Administration or in the one of the big hospital groups, should exercise some leadership and mandate connector incompatibility within a short (say, under three years) timeframe.  After that, bring in the trial lawyers and let 'em have at it.

It's not rocket science, you know.

Posted by: Old Grouch in In Passing at 15:56:34 GMT | No Comments | Add Comment
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