The Joint Commission's Sentinel Event alert last week warning of the hazards of misconnected medical tubes harkened back to how anesthesiologists addressed similar issues in the prehistory of the patient-safety movement.
Two prominent anesthesiologists say the issues are much more complex today and applaud the Joint Commission for putting the industry on alert.
Their specialty, as noted in the 1999 Institute of Medicine report To Err is Human: Building a Safer Health System has a long history with the subject. The report credits anesthesiologists for pioneering the use of human-factors engineering to design equipment that blocks serious errors by making it difficult to attach tubes to the wrong equipment. It also cited anesthesia patient-safety studies published in 1954, 1961 and 1978 as evidence of the specialty's long-standing interest in promoting safety.
Dr. Donald Martin, professor of anesthesiology at the Penn State College of Medicine, said the issue goes back to at least World War II. The website for the American Society of Anesthesiologists' Wood Library Museum has an item on the Ohio 685 Military Machine, affectionately referred to as “the pig.” Using patterns of pins and holes, its “yoke” was designed so it was nearly impossible to hook a tube to the wrong gas tank.
Standards were set so meters for oxygen, nitrous oxide and suction tanks each always featured the same color coding. The tanks also were always in the same sequence, and even the knobs for each tank had their own feel.
But this level of standardization is still a work in progress with modern intravenous tubes, Martin said.
“It may be getting worse as the equipment gets more complex and the number of manufacturers is increasing,” said Martin, who serves on the ASA's committee on equipment and facilities. “As physicians go from one hospital to another with different devices and different systems, it becomes an issue.”
The Joint Commission described examples of fatal misconnections, including a feeding tube linked to a tracheotomy line and an IV tube connected to an epidural source. The organization's literature review identified 116 case studies where a feeding solution had been misdirected into IV lines, leading to at least 21 deaths. And these types of adverse events are believed to be underreported, according to the alert.
“I'm sure it's underreported,” said Dr. Stephen Small, associate professor at the University of Chicago's department of anesthesiology and critical care. Small was a co-author of a groundbreaking 1995 study (PDF) that identified 247 adverse drug events at 11 units inside Brigham and Women's and Massachusetts General hospitals in Boston during a six-month period in 1993.
“Reporting is still highly problematic,” said Small, who serves as director of the University of Chicago Simulation Center. He added that the key is to simplify reporting while simplifying the connections.
“Healthcare is becoming more and more complex with more and more device manufacturers who may or may not be working together,” Small said. “What if we had 10 different types of electrical outlets in our homes with 10 different types of plugs? What if something went terribly wrong if the wrong one was hooked up?”
A seriously ill patient could be connected to 10 or 15 tubes, Small said, so it's particularly dangerous when a patient has to have an MRI or some other diagnostic test done that requires this complex tapestry to be unwoven and then put back together again.
“I thought the Sentinel Event alert was good,” Small said, because it brought attention to an issue that is rarely addressed uniformly throughout an institution or hospital system.
The International Organization for Standardization, the Association for the Advancement of Medical Instrumentation, clinicians, manufacturers and regulators are collaborating on a new set of standards for tubing connectors that will be introduced this year and next.
Still, problems could persist during and after the rollout, until supplies of nonstandard tube connections are depleted.
“This transition has not been formally designed, has not been planned for, is not engineered for safety and there are no federal plans to guide the rollout,” Martin said. “It's kind of like each hospital is on its own to plan and to prevent problems.”
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