The way Carrie Gavriloff sees it, you should never judge a tube by its color.
When the education coordinator of nursing products for Akron Children’s Hospital heard about an international effort to improve the safety of tube-feeding supplies, she challenged the concept of using color-coded items.
If nurses or other caregivers rely on color alone, she thought, deadly mistakes still can happen.
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So Gavriloff wrote a letter to an industry association and asked: Why not design the devices so the wrong connections simply won’t fit together? A square peg can’t fit in a round hole.
Industry leaders listened.
Gavriloff and Akron Children’s inpatient pharmacy manager Mary Ann Allen traveled to Germany this month for the first in a series of high-level international meetings to share their ideas globally.
Those meetings could result in a worldwide overhaul of feeding-tube connectors within the next several years.
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”Nurses, in our brains, we’re always trying to think of ways to make it safer and better for our patients,” Gavriloff said.
These days, it’s not uncommon for patients to have numerous medical lines for tube feedings, IV medications and treatments and monitoring.
The Joint Commission issued a warning several years ago to alert hospitals and other medical services to mistakes in which caregivers accidentally connected the wrong tubes, resulting in deaths.
The U.S. Food and Drug Administration has documented a variety of fatal errors: Epidural medication delivered into an IV. Milk mistakeningly administered through a trach tube into a baby’s lungs. Oxygen tubing accidentally reconnected to IV tubing, causing a deadly air embolism.
Many times, the Joint Commission found, these misconnections involve what are known as ”luer connectors,” or small devices used to attach medical components and accessories.
The luer connectors ”enable func
tionally dissimilar tubes or catheters to be connected,” warned the commission, a voluntary accrediting group.
Akron Children’s hasn’t had a serious connection mistake, Gavriloff said. But the potential is there industry-wide unless the devices are modified to prevent human error.
”What will end up happening is you end up putting breast milk into a vein, and that’s not supposed to be in there,” Gavriloff said.
Letter sparks meeting
Last year, Gavriloff learned some industry leaders were considering using color as one way to differentiate medical tubes and connectors.
The news prompted her to write a letter to the Assocation for the Advancement of Medical Instrumentation (AAMI) that was co-signed by Dr. Michael W. Bird, the hospital’s vice president of medical services, and John Lepto, pharmacy services director.
In the letter, Gavriloff and her colleagues urged the association not to use a specific color to denote feeding connectors, also known as enteral connectors.
”We recommend that the enteral connectors be made square or triangular in shape,” she wrote. ”By having a dissimilar shape, providers will be unable to take a triangle or square and place it into the circle of the luer connection.”
AAMI is representing the United States in a worldwide effort to develop voluntary standards through the International Standards Organization (ISO) for medical tubing connections.
Gavriloff’s letter was forwarded to Brad Noe, who is the U.S. co-chairman of a technical advisory group that is developing ISO standards for feeding tubes.
”I have to give them a lot of credit for writing that letter and taking a look at it and saying, ‘We want to have an impact for our kids,’ ” said Noe, manager of technical resources at Becton, Dickinson and Co., a medical and diagnostics device company based in New Jersey. ”It would have been ‘shame on us’ to not respond appropriately to them.
”I called and said: ‘We concur with your thinking. So would you like to learn more about what’s going on?’ ”
Ideas take shape
The hospital’s group purchasing organization, Med-Assets, became involved and offered to send the two representatives from Akron Children’s to Germany for a meeting.
Gavriloff and Allen joined about 40 international leaders, including representatives from the FDA, Nestle, Dannon, Kimberly Clark and others.
”In the beginning, we listened,” Allen said. ”And then when we got to see the products, we would say, ‘This doesn’t look like it would work,’ or, ‘This could connect to this.’ ”
Gavriloff said she and Allen stressed the importance of making products safe for children by avoiding potential choking hazards in the design.
The two also encouraged designers to avoid creating products that could injure nurses and other caregivers.
”As much as we learned from the engineers, we offered them just as much,” Gavriloff said.
It’s important for people who care for patients to be involved with the design if changes are going to be widely accepted, Noe agreed. ”They are bringing the real world to what could be a distant and removed set of circumstances.”
The next meeting will be in October in Seattle.
The goal is to adopt new international standards by 2013, when a law takes effect in California banning hospitals there from buying feeding-tube, spinal and IV supplies that can interface, Noe said.
Cheryl Powell is a health reporter for The Akron Beacon Journal, the daily newspaper in Akron and a syndication partner of MedCity News.
