The Problem Of Look-Alike Tubes

The New York Times has a detailed, important article on an issue every nurse is aware of: the fact that tubes for different functions are interchangeable and easily confused, resulting in injuries and death every year. Those tragedies are due to long-standing defects in the design of the equipment but invariably get blamed on the nurses, who must distinguish between identical-looking tubing and attach and unattach and reattach them countless times during the day, often during high-stress moments.

Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible — just as different nozzles at gas stations prevent drivers from using the wrong fuel.

But action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.

Hospitals, tube manufacturers, regulators and standards groups all point fingers at one another to explain the delay.

Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.

Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences.

One advocate for change said it best: “Nurses should not have to work in an environment where it is even possible to make that kind of mistake,” said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. “The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death.”