Medical misconnections: Patient-safety problems

By David Wahlberg
Wisconsin State Journal

After a nurse's medication error killed a teenager during childbirth in Madison last year, the public controversy – and the media coverage – focused on a felony charge against the nurse.

As I reported on the charge, which was reduced to two misdemeanors in a plea bargain, I learned that the incident touched on health-care system issues much deeper than whether or how providers should be punished for mistakes.

Julie Thao, the nurse, had inadvertently given 16-year-old Jasmine Gant an epidural anesthetic in her intravenous line, where Gant was supposed to receive penicillin. Thao failed to follow several steps that could have prevented this. She didn't observe a label on the epidural bag warning that the drug must be given near the spine, and she didn't use a bar-code scanner on the drug or on Gant's wristband.

But a medical equipment vulnerability also enabled the mix-up. The top and bottom ends of epidural and IV tubes have spikes and connectors that are interchangeable. This allowed Thao, a 13-year veteran of the hospital's birthing unit, to deliver the epidural into Gant's IV catheter – in what is known as a tubing misconnection.

Furthermore, Thao likely was exhausted that fateful day. She had worked two eight-hour shifts in a row the day before, ending at midnight. She slept at the hospital before starting the 7 a.m. shift during which Gant died.

In talking to people about tubing misconnections, I learned of another problem two local nurses were trying to solve: incompatible connectors on defibrillator chest pads. Emergency medical workers must frequently switch heart-attack patients' chest pads en route to a catheterization lab because police, paramedics, community hospitals, helicopter services and big-city hospitals often use different brands of defibrillators. When patients' heartbeats are being maintained with "external pacing" from the defibrillators, the interruption in electricity can be fatal, according to the nurses and other emergency medical workers.

My editor and I agreed these issues were ripe for more reporting. For about four months, I spent about two-thirds of my time on this. The result was a five-day series, "Medical Misconnections: Patient-Safety Problems and Solutions."

The first thing I did was ask the state health department for all "statements of deficiencies" from inspections dating back to 2000 at Thao's hospital and the two other main hospitals in town. Though Wisconsin, like most states, doesn't gather much data on medical errors, the inspection reports revealed mistakes at the other hospitals. In one case, a sponge was left in a surgery patient who died. In the other, a patient was given a fatal overdose of Heparin.

I talked to malpractice attorneys, who directed me to lawsuits in those cases. The attorneys pointed to other medical errors at nearby hospitals, including a surgery on the wrong side of a patient's brain and a 13-inch retractor left in a woman's abdomen during cancer surgery.

The attorneys also told me about three other tubing misconnections, two involving IV fluids mistakenly given in the spine and one in which Metamucil was given in an IV line instead of a feeding tube. Like the Gant case, these errors – two fatal, one causing permanent paralysis – were enabled by interchangeable tubing connectors.

I learned that patient-safety groups were starting to bring attention to tubing misconnections. The Joint Commission had issued a sentinel event alert on the topic three months before Gant died.

I contacted U.S. Pharmacopeia, the drug industry standards agency. The Joint Commission's alert had said that USP had reported 300 tubing misconnections around the country. USP staff agreed to crunch new data for me and said the tally had grown to 1,200 incidents. That is a fraction of the national total, since hospitals' reporting to USP and to other databases is voluntary and anonymous. Still, the figure helped my readers understand that the Gant case wasn't an isolated incident.

I wondered if anybody was trying to solve the problem. I contacted the Joint Commission, the Food and Drug Administration, the Association for the Advancement of Medical Instrumentation, the Institute for Safe Medication Practices, the ECRI Institute and other organizations. They told me that the European standards agency for medical equipment proposed different sizes or shapes of connectors for different kinds of medical tubing, which could prevent most tubing misconnections.

I studied the European proposal. But these organizations also told me that a lack of financial incentives among medical device companies to make these new connectors was among the obstacles hampering a solution internationally and in the United States. I learned that the same obstacles apply to incompatible defibrillator pads.

The last main step in my reporting on tubing misconnections was to figure out how medical tubing works. I had read about it but was confused. I organized what my sources and I jokingly called "continuing education sessions." Nurses, pharmacists, patient-safety officers and others at local hospitals showed me different kinds of tubing and let me connect and misconnect it. I arranged similar sessions about other equipment I wrote about, including bar-code scanners, sponge counters, smart pumps and pharmacy robots.

In researching nurses' working hours, I learned that the Institute of Medicine recommended that nurses be banned from working more than 12 hours in a row because studies have shown an increase in errors among nurses who work longer hours.

To learn more about nurse staffing and scheduling, I interviewed many nurses and nurse managers. On one visit, a graphic artist joined me. He and I created an interactive Web exercise in which users can learn what makes staffing a hospital unit with nurses complicated.

Local hospital officials were cooperative with my efforts, and their feedback to my series was positive. They welcomed my desire to explore system-wide issues of patient safety rather than to only blame them for particular incidents.

Tubing misconnections, incompatible defibrillator pads and nurse fatigue are emerging issues around the country, with potential stories for reporters covering health care in any market.