Safety experts watch Sunrise

National medical safety experts are closely following news accounts of what Sunrise Children’s Hospital officials have called incidents of "disrupted catheters" that have left one newborn baby in critical condition.

Another infant had to undergo an emergency operation as a result of catheter disruption, the hospital disclosed in a Friday statement that also revealed there have been 14 such incidents since February. Two Sunrise nurses, Jessica May Rice and Sharon Ochoa-Reyes, have been named in a Las Vegas police investigation into "intentional patient harm" and have had their licenses suspended by the Nevada State Nursing Board.

News of the Sunrise situation has "spread like wildfire in safety circles," said Mike Cohen, head of the Pennsylvania-based Institute for Safe Medication Practices, which sends out a regular safety bulletin to hospitals throughout the country.

"Everybody is trying to figure out what happened," he said. "Nobody knows what the hospital means by ‘disrupted catheters.’ "

A catheter is a tube that can provide nutrition and medication to a patient.

While acknowledging that medical personnel have been known to act as "angels of death" in deranged efforts to relieve a patient of his or her misery, the safety experts are raising one major question based on problems found at hospitals throughout the country.

Could the disrupted catheters at Sunrise, — which hospital officials first thought stemmed from technical problems — have malfunctioned because outdated engineering allows human error?

The national Institute of Medicine estimates that as many as 98,000 people die each year because of preventable medical errors.

"You can’t put diesel fuel in your gas tank, but you can inadvertently mix medication and nutrition for a baby through a tubing misconnection," said Debora Simmons, head of the Houston-based National Center for Cognitive Informatics and Decision Making in Healthcare. "As a safety researcher, I’ve been looking at this problem of tubing misconnections for seven years. The medical industry is probably the only industry that designs things where anything can connect to anything."

"It’s craziness," she said. "We don’t recognize in the way our medical equipment is manufactured that people can make mistakes. When it comes to public safety, when it is at all possible, you have to engineer things so they are incompatible. Don’t you think a lot of people might be ruining their engines by mistake with diesel fuel if engineering hadn’t made it impossible to do?"

Simmons said it is difficult to expect that busy critical care nurses, though highly trained and well intentioned, will never make a mistake. She noted that a critically ill patient has tubes of one sort of another inserted into much of his body.

Often working quickly in low light to connect IVs for medication and fluids as well as feeding tubes, nurses may sometimes forget to look at where the tubes originate, Simmons said.

"The best solution is to design tubes so that the ones that shouldn’t fit together don’t," she said, arguing that the cost of re-engineering equipment is largely the reason it hasn’t been done.

Cohen noted that his organization reported to hospitals across the country in 2006 that tubing used to deliver breast milk to a baby was mistakenly connected to an IV delivering medications.

"The baby had seizures and respiratory distress but recovered," he said. However, many babies in that situation die, he said.

"We write about these kind of incidents a lot," he said. "Designed incompatibility is necessary to prevent dangerous misconnections of tubes and catheters."

Not only children suffer because of tubing misconnections, Cohen stressed.

Several people have died after tubing from a blood pressure machine or an oxygen mask was mistakenly connected to an IV tube supplying fluid and medicine into a vein. The wrong connection allowed air to enter the vein, causing a fatal embolism.

On July 9, the same day Sunrise officials disclosed problems with catheters in its children’s hospital, officials with the nation’s Food and Drug Administration wrote a letter about misconnections in medical tubing to manufacturers of medical equipment and health care authorities throughout the country.

The ease of connection has "led to misconnections that have inadvertently linked unrelated systems, and at times, have resulted in serious adverse events. In particular, misconnections with … feeding tubes and solutions have been associated with serious death and injury," according to the FDA.

The letter suggests manufacturers make design changes that include color coding and adopt the principle "of designed incompatibility, to ensure that devices that should not be connected cannot, in fact, be connected."

On Wednesday, Sunrise officials and police investigators continued to decline comment about the disrupted catheters.

Neither Rice nor Ochoa-Reyes was available for comment Wednesday.

Both of the national safety officials interviewed by the Review-Journal want to believe that neither nurse could have hurt babies intentionally.

"I really want to believe that we’re talking about accidents," said Simmons, who studies incidents around the country.

"It’s highly unusual for nurses to get together to do harm to patients. But 14 of these accidents since February? That’s a lot of accidents."

Contact reporter Paul Harasim at pharasim@review journal.com or 702-387-2908.