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Medical and Government Inaction Cause Patient Deaths

It took me awhile to write this particular blog. The article it is based on was published in the The New York Times on August 20, 2010. Here it is, three weeks later, and I still can’t quite understand how this is allowed to happen. Get ready…this is heartbreaking and disturbing.

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. [The New York Times]

Every year, hundreds of hospital patients die or are seriously injured when hospital staff administer treatment into the wrong type of tube. A survey found that 16 percent of hospitals report this kind of confusion. (Given that there are about 5800 registered hospitals in the United States, that means that at least 928 hospitals–an average of about 18 hospitals per state–have experienced a potentially serious mix up.)

Now, when I need a charger for my cell phone, I can only use the brand and size designated for my particular phone. A Nokia charger can’t be used on an iPhone, and a Blackberry charger can’t be used on a Sidekick. Other mundane items–batteries, lightbulbs, car parts, gasoline nozzles–are sized in such a way that the wrong part can’t be used in an inappropriate way. That isn’t the way hospital tubing is made, even though small amounts of a wrong substance can potentially kill a person.

Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.

Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences. [italics added]

What kinds of accidents have happened? According to The New York Times, blood-pressure cuffs have been connected to intravenous lines (leading to deadly air bubbles in veins), bags of fluids have been connected to oxygen tubes (leading to drowning deaths), anesthetics have been mistakenly connected to venous tubes (killing a patient who was giving birth), and just about any other permutation you can think of.

Who is Responsible for Fixing This Mess?

Let’s set aside, for a moment, the question of who is legally responsible for the patient deaths and injuries. But who is responsible for fixing the problem? Despite calls for action, the medical-device industry is resistant to change…and the Food and Drug Administration (FDA) has paperwork roadblocks that discourage change.

“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.”

The FDA has sent out medical safety alerts, warning that Luer connectors facilitate connecting the wrong tubes to the wrong treatment. They provide guidance about how to “help prevent” misconnections, but there is, to date, no action to prevent this danger.

HensonFuerst Attorneys are grateful that The New York Times has done this investigation, and we would like to add our voice to those calling for manufacturing and regulatory changes. We will keep monitoring this situation, and will report back if there are any developments.

To read the full article from The New York Times, click here: U.S. Inaction Lets Look-Alike Tubes Kill Patients

To read more information about Luer misconnections, click here: FDA Resources

If you believe you have been injured by a mistake made by a hospital, doctor, or nurse, and you have questions about your legal options, visit our website at www.hensonfuerst.com. If you have questions, HensonFuerst has answers.

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