There was a case several years ago that involves a mistake involving a feeding tube being coupled with a tube that entered a pregnant woman’s vein, instead of with the tube that entered her stomach. It is such a sad story that not only led to the woman’s death but also to the death of her unborn child. This story and others like it, highlight the urgent need for stricter federal oversight.
For years patient safety experts have been pushing for changes, but the medical device industry has been resisting change and others have been dragging their feet. In some cases, manufacturers have turned to color-coded tubing, but some say that has just made the situation more confusing.
In a recent story by The New York Times, healthcare leaders talk about their concern:
“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.”
“This is a deadly design failure in health care,” said Debora Simmons, a registered nurse at the University of Texas Health Science Center who studies medical errors. “Everybody has put out alerts about this, but nothing has happened from a regulatory standpoint.”
Advocates in California got legislation passed in 2008 that would have mandated that feeding tubes no longer be compatible with tubes that go into the skin or veins by 2011. But in 2009, AdvaMed, the manufacturers’ trade association, successfully pushed legislation to delay the bill’s effects until 2013 and 2014 or until the international standards group reaches a decision.
AdvaMed should be pushing forward to make needed changes. It is of great concern that the association would drag its’ feet. Patients and healthcare industry leaders need to insist that changes be made. Be vocal and share your concerns in order to demand change.
Patient safety needs to come first. It is irresponsible to allow this safety flaw to continue after all these years.