Sunday, August 22, 2010

“Common Sense is Very Uncommon”—Horace Greeley

As the New York Times pointed out in an article on 8/20 about misplaced tube feedings, system problems can be the cause of complications and deaths in many instances. And it is certainly easier on everyone to blame the system rather than an individual. However, sometimes it really is someone’s fault. The problem with tube feedings which has existed for at least 30 years is that the connections for the tubing are often similar to the connections for intravenous fluid tubing. If one is not careful, feeding meant for the GI tract can be delivered intravenously with disastrous results.

Here is my question. How could a nurse make such a mistake? Yes, it would be better if the tubing connections were different and regulations requiring this are long overdue. But where are the elements of due diligence and common sense? No doubt the order for the GI tube feeding stated that it was to be given via the stomach tube. Even when diluted, GI tube feedings have the consistency [but not the color] of pea soup. With the exception of blood and a few other special items, intravenous solutions are clear. How could anyone look at a solution containing GI tube feedings and assume it would be OK to infuse it through a vein?

System issues must be addressed but the human element still exists. A 2007 paper from a highly regarded trauma center showed that the leading causes of preventable and possibly preventable trauma deaths were delays in treatment and errors in judgment, which are two factors unlikely to be eliminated by changes in systems.

I think all of this represents a slide toward mediocrity and lack of accountability our country has been on for many years. This is highlighted by another Times story in the 8/22 edition on stupid things people do in our national parks. Among the many sadly believable tales is one recounting a group of hikers summoning a rescue helicopter on two occasions [at $3400.00 per flight funded by us, the taxpayers] because first, they were low on water and second, the water in the park “tasted salty.” Regarding the problem of hikers becoming lost, spokesman for one of the parks is quoted, “We have seen people who have solely relied on GPS technology but were not using common sense or maps and compasses, and it leads them astray.”

Go ahead and make all the system changes you can think of. I guarantee you that after the GI feeding tubing connections are finally mandated to be incompatible with IV tubing, someone will still find a way to mistakenly deliver food meant for the stomach into a vein.


Curinga said...

This is a very interesting topic. One of these days I was talking with my circulating nurse, who happens to also work at a neonatal ICU, and she told me that she is no suprised these erros occurs, because often there are many lines, long ones, attached in circles so as to the baby do not take it of (and still they do), some of them in infusion pumps, so they need to pay attention all the times. Also, the parenteral nutrition may look alike enteral nutrition and vice-versa. As she is very smart working girl, I know she doen't commit those erros, but one can see how a undermotivated, dumb, tired nurse go for it. Surely, nurses should be careful, but tubings could also be more easily identified or incompatible.
Recently, here in Brasil, there have been some cases of enteral feeding injected intravenously, and they have drawn too much attention from media. I didn't know these kind of things happened in USA too.
I am very surprised that it has been a issue for 30 years and no one put the obvious end on it.
Another source of anxiety is the epidural cateter. Certainly not the best way to administer drugs and food.

PS I found your blog one month ago. Today I finished reading it. Someday, if you're interested, I'll tell you something about med school and residency in Brasil.

Skeptical Scalpel said...

Thanks for commenting. I'm sure you must have heard about this case

I would love to hear about med school and residency in Brasil.

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