Feeding Tube Mistakes During Pregnancy Lead to Death and Despair

John Fisher
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Stopping Medical Injustice

The misuse and poor design of feeding tubes is leading to countless deaths, including those of pregnant women, unborn children, and infants. However, both the Food and Drug Administration and the manufacturers of the tubes are dragging their feet when it comes to removing them from circulation. This week, The New York Times reported on how feeding tube "mix-ups" most likely occur in about 16% of hospitals each year. This mistake may occurs when liquid-food bags are connected to a tube entering a patient's veins instead of to their stomachs. According to experts putting food directly into the bloodstream "is like pouring concrete down a drain". Such mistakes can result in serious injuries, and death.

The New York Times told the stories of two patients that had been victims of this mistake: Chloe Back, a premature infant who was being fed breast milk through feeding tube to help her gain weight and Robin Rodgers, a pregnant woman whose doctors chose to hospitalize her and have her fed through a tube in her stomach until her baby's birth because she was vomiting and losing weight. A nurse mistakenly connected a bag of breast milk to an intravenous tube connected to Chloe's veins instead of to her stomach feeding tube which led to the formation of blood clots throughout her body, profuse bleeding and seizures. Robin's nurse connected a liquid-food bag to a tube entering Robin's vein instead of snaking he tube through her nose and into her stomach. Due to the mistake, Robin's baby died shortly after the misconnection, and Robin died in agony soon after.

Tubing mistakes may also occur when tubes intended to inflate blood-pressure cuffs are connected to intravenous lines or intravenous fluids are connected to tubes intended to deliver oxygen. The mix-up of feeding tubes has been a problem for decades. Hospitalized patients have a number of tubes connected to their bodies that may deliver medicine, food, blood, and fluids to numerous veins, organs, and arteries. The fact that most tubing is interchangeable makes it easy for mix-ups to occur.

Although advocates have pushed for increased regulation by the FDA, and new designs that would make tubing unique to its particular usage, change has been slow. In 2008, legislation was passed in California that would have mandated that feeding tubes no longer be compatible with tubes that go into the skin or veins However, tubing manufacturers have been able to delay the bill's effects. Furthermore, the FDA's approval process is flawed It requires "only that the manufacturer prove that a new product works just like an old one, whether the old one is safe or not". According to the New York Times, no clinical testing or proof of safety is usually needed. Although the FDA has now started a reassessment of its device approval process, it will take quite awhile before the tubing can be taken off of the market.

I hope that the FDA and tubing manufacturer’s decide to take charge of this problem immediately. Tubing mistakes have been occurring for far too long. I hope that nurses are being educated about how easily mix-ups can occur and how vigilant they must be when connecting intravenous bags and liquid-food bags. I am appalled that this mistake has been occurring for as long as it has especially since it can have such dire consequences. The FDA must take action immediately, and manufacturers should start thinking about the lives of future patients instead of their bottom line.







1 Comments
Stupid question. Since the tubes aren't likely to be changed in design soon thanks to the FDA, why not go around them? I work on electronics often, as well as mechanical work, and whenever I have a lot of wiring or hoses to organize, I simply write a little tag on a piece of adhesive tape or labeling and stick it on them for identification purposes. So why can't the hospitals do that? It'd take less than 10-30 seconds to do, and save millions to billions in malpractice suits.
by Brian O'Connell August 26, 2010 at 03:45 PM
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