Blunders and Wonders: Misconnecting Equipment & Drug Delivery

Nick van Terheyden, M.D.
NOVEMBER 08, 2018
Hello! I’m Dr. Nick the Incrementalist, and I’m here today to talk about Blunders and Wonders.

Blunder: Misconnecting Equipment

This week’s Blunder: Misconnecting equipment. We are not big users of diesel fuel for cars in the US, but on the European continent it’s very popular. For anyone visiting who’s not familiar, they might make the mistake of taking the commonly found diesel nozzle and putting that into the gas tank of a gasoline or petrol driven car. In fact, that’s mostly not possible since the nozzle is designed to be bigger, so it won’t fit into the gas tank opening. It’s a simple but effective safety measure.



The same principle has been applied to anesthesia – removing as many opportunities for errors by standardizing on connectors for specific gases and cylinders that prevent connection of the wrong line to the machine.

Sadly, this is not a pervasive safety measure throughout healthcare and you only have to watch one of the latest Hollywood medical dramas or set foot into a hospital to see the array of tubes and connectors that are ever-present at the bedside. We use these connectors for a wide range of medical support to the patient that includes nutrients and drains. Misconnecting these tubes to the wrong source can result in serious medical issues like delivering the wrong product to the wrong part of the body.

Creating a standard for each of these connectors that prevents the connection of a nutrient line to a venous or arterial line on a patient is a simple safety feature that would go a long way toward reducing errors. The FDA has urged making the connectors uniform to prevent misconnects, but these are voluntary guidelines and misconnects continue.

In the interim, for your incremental step, don't modify or adapt intravenous or feeding devices. Use color coding if at all possible and trace lines from end to end every time there’s a change or as part of a hand off.

Wonder: Treatments That Keep On Giving

This week’s wonder: Treatments that keep on giving. We have a range of treatments that require continuous medication to maintain an appropriate dose to treat disease. No matter what we give to a patient, the extraordinary body systems are designed to get rid of substances from our body, and that’s true of drugs we use to treat disease. You’ll be familiar with that if you take any medication, as the majority come in the form of a pill that you take once every day, sometimes multiple times per day. For tablets it’s relatively easy to maintain the appropriate dose, but for drugs that must be injected, that creates some challenges – especially if access is limited.

Such is the case for a treatment of age-related macular degeneration that causes blindness. Unfortunately, despite finding a highly effective drug that can prevent the disease, we still see a lot of people going blind because it has to be administered by injection every 6-8 weeks, which is a challenge for elderly patients who lack good access to transportation.

The research presented at annual meeting of the American Academy of Ophthalmology (AAO) recently offered a new hope, showing off an implantable drug delivery system that meant patients could go up to 15 months between injections. But the news, in my mind, is even better since this methodology can be applied to other drugs and potentially in other countries where access to healthcare can be even harder and less frequent and consistent, like Africa. Now it might be possible to develop low cost delivery mechanisms for other lifesaving drugs as well as this one.

Until next time I’m Dr Nick, the Incrementalist – don’t let perfection stand in the way of progress.

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