Medical errors that shouldn’t happen

Summer activities have kept me away from blogging and I have a backlog of potential posts, but this one motivated me to finally break my inaction inertia:

The article is about medical errors in which patients are severely injured (or die) when the wrong tube is connected to them. For example, a blood pressure tube (which carries pressurized air) is accidentally attached to an intravenous line. There are two points to emphasize: (1) like many challenging quality problems, these errors are rare but not rare enough, especially if you are a victim of one and (2) the solution seems painfully obviously and surprisingly hard to implement.  Consider the frequency of this error. Nurses know that switching tubes can caused big problems and so they are very careful nearly all of the time. But given the number of patients each day that are at risk of a tube mismatch, errors will occur even if six-sigma quality is in place. The obvious solution is to eliminate this potential error by making the tubes incompatible – if the blood pressure tube can’t fit into the intravenous line, then even if the nurse attempts this connection, the error will be avoided.  The problem with this solution is that it requires coordination across numerous government agencies (within the U.S. and across countries) and many more companies. Nevertheless, failure to do something to do something seems negligent at best.

The article mentions another area in which the problem apparently has been solved – fuel filling stations. The idea is that you shouldn’t be able to put a gasoline nozzle into a diesel car and vice-versa. Of course, the number of fuels is much smaller than the number of tubes that can be stuck into a body, so you would think that at least this problem has been solved. But from personal experience I know that it was not solved (at least about 5 years ago) because I managed to fill my rental mini-van in France with 120 euros of petrol only to discover about 2 kilometers down the road that I had rented a diesel mini-van. (On a positive note, the white cloud that appeared behind our vehicle did amuse the kids in the car.) Nobody was injured but the engine needed (I was told) very costly repairs. Avis didn’t make a lot of money on that rental and I wonder why they don’t train their employees to mention to their customers that they really should pay attention to the fact that they are renting a diesel mini-van and not a gasoline mini-van. It is simply an important “safety tip”, like “don’t cross the beams” (for those of you who remember Ghostbusters).


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