I just wrote yesterday about hospital errors causing injuries and deaths needlessly. Now an article from the New York Times brings up a point that most hospital patients would never even consider — you can die because a nurse or aide hooks up your feeding tube to your medication IV, or vice-versa. The article is important reading for anyone about to enter a hospital or who has a friend or relative in the hospital.
The Times reported that “hundreds of deaths or serious injuries” have occurred due “to tube mix-ups” in hospitals. To prevent this problem, “experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible.” The failure to make the change is due to “resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.” Dr. Kevin McBryde, an FDA reviewer, is among several agency employees who have argued that some of these tubes are unsafe, but was “overruled” by a supervisor. Meanwhile “an international standards group is seeking consensus on specific designs on how tubes for different bodily functions should differ, but the group has been laboring for years and its complete recommendations will take years more.” Here are the opening paragraphs:
Thirty-five weeks pregnant, Robin Rodgers was vomiting and losing weight, so her doctor hospitalized her and ordered that she be fed through a tube until the birth of her daughter.
But in a mistake that stemmed from years of lax federal oversight of medical devices, the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers’s nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein.
Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony.
“When I walked into her hospital room, she said, ‘Mom, I’m so scared,’ ” her mother, Glenda Rodgers, recalled. They soon learned that the baby had died.
“And she said, ‘Oh, Mom, she’s dead.’ And I said, ‘I know, but now we have to take care of you,’ ” the mother recalled. And then Robin Rodgers — 24 years old and already the mother of a 3-year-old boy — died on July 18, 2006, as well. (She lived in a small Kansas town, but because of a legal settlement with the hospital, her mother would not identify it.)
Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. A 2006 survey of hospitals found that 16 percent had experienced a feeding tube mix-up.
