Too standardized? – The problem of tube identification in hospitals

When it comes to efficiency, creating standard sizes and connections saves money, production efforts, and makes for easy substitution when one runs out of an object. For example, I was delighted that lid for one brand of pot perfectly fit my new frying pan. Unfortunately, there are times when we do not want parts of one object to fit another because it can encourage dangerous errors.

The New York Times ran a recent article on the similarity between the many tubes used in hospitals for different purposes. These purposes include:

  • Intravenous use
  • Inflating blood pressure cuffs
  • Feeding tubes

Obviously, very different materials pass through each of these tubes, and mixing one with another can be deadly. The article discusses several cases where food or air was passed into patient veins. The tubes entering the patient are often compatible with multiple sources of input, with no guard besides notoriously fallible human attention to prevent a mistake.

From the NYT article:

…the F.D.A. has issued three alerts to hospitals and manufacturers warning about tube mix-ups, the most recent of which was sent out last month after The Times began asking about the issue. Ms. Pratt said she persuaded one manufacturer, Viasys, to produce neonatal feeding tubes that are incompatible with other tubing. Viasys’s tubing is now used in Sharp’s neonatal intensive-care units, but they are expensive — $13 compared with $1.50 for regular tubes.“The regulators have been waiting for the manufacturers to come up with a solution,” Ms. Pratt said, “and the manufacturers won’t spend the money to design and produce something different until the regulators force them to. And now the international standards organization is taking forever to get the whole world onto the same page.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, agreed, “These things are hard to change when you have to get so many different organizations to act in concert.”

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