2 DB questions and replies
__________________________
-
e effects of an enteral feeding solu Robin’s intravenous central line, the
‘n Drug Aflergy” is about a woman ing an antibiotic prescribed to treat real name) had a history of allergic ords clearly documented her drug rror was not detected when Zova’s due to the use of a hybrid medical scription was written on paper and I electronically after the patient had e error was also not detected when by the pharmacy Zoya died from
)rrise and Kirsten Morrise and tells jorn with a genetic condition called Trial Meant for Ydu: The Lifelong •h a Complex Congenital Condition” nces and lessons from a lifetime of ing with the events surrounding ecognize her condition led to a series
ok, we caution the reader that these elements of other competencies as
is helpful to think about the other (Refer to the full list of competencies
CASE 18
Not for IV Use: The Story of an Enteral Tubing Misconnection
The Story of Robin and Addison Lowe (United States)
Gletida Rodgers
Editors’ Note Glenda Rodgers is i veteran nurie with ii jore than 25 vcan ‘ expenenc in obtet’t ‘itas— lug il1II se’Z’c’flhl veal’s e.vperiencc’’aorking in i)iipleineiihitioii / electronic ,,;cdcal records. Glenda ilaughter Rob in Lowe was i nit esing technician in a,th mi/v practitio— nel’:c office. Robin wanted to he a nurse like her mother and was plaiiinny to go to ‘zitl:cini school.
At tb’ ti,ne f’the ‘-t’ents described in thh case, RoI’i,i was married and l’ada ?—year—oL? son, She -zeas pg with her second chi11, a ilnighte ,- whom ,he a,ll he,’ hushani Jeremy had named Addison, On a summer morning in her eighth month ofpregnancv, Robin went to the eine;gencl’ room with .‘et ‘crc nausea and abdoini nilpain a cjnglitioii that had bee,, an issue thro ugho at the pie gna ney She was ad,,, it/ed to the hospitaljbr ear/v induction of7thor fly the end ol’the lay Roi’n, ani her unborn ,lanhter were dci,? floin the ffi’’tc o/’in enterzl /c’eiing solution that hail bee,, iii/isel into Rohi,, inti’i— venous centi-al line, the result ofa tubing ,nisconnection. ihefrilowing is Glenda Rodg— n-s’s account of her cianghterc medical history, the c-tents sni’;-oundniç’ Rohi,ic hospitalizatio,,, ,i,,d the untimely deaths of Robin an/Addison Lowe,
231
L E
A R
N IN
G O
B JE
C T
IV E
S po
t fe
w er
an d
fi rt
he r
b ev
ee n .
B y
th e
tim e
sh e
gr ad
ua te
d fr
om hi
gh A
ft er
co m
pl et
in g
th is
ca se
st ud
y, yo
u w
ill he
ab le
to :
1.. E
xp lo
re th
e sc
ie nt
if ic
fi el
d of
hu m
an fa
ct or
s 4I
d ho
w er
ro rs
l.i ke
tu bi
ng m
is co
nn ec
ti on
s ca
n be
pr ev
cn te
d. 2.
D is
cu ss
th e
co m
pl ex
ity of
ha vi
ng tw
o pa
ti en
ts to
tr ea
t, a
m ot
he r
an d
he r
fe tu
s. 3.
D es
cr ib
e su
ita bl
e ac
tio ns
by he
al th
ca re
st af
f f ol
lo w
in g
th e
di sc
ov er
y of
an er
ro r.
4. D
is cu
ss en
gi ne
er ed
fo rc
in g
fu nc
tio ns
an d
ho w
th ey
ca n
he us
ed to
m ak
e m
ed ic
al de
vi ce
s sa
fe r.
B ac
k g ro
u n d
O n
Ju ly
18 ,
20 06
, m
y d
au g
h te
r R
ob in
w as
ad m
it te
d to
th e
ho sp
it al
. S
he w
as 24
ye ar
s ol
d, an
d sh
e w
as 35
w ee
ks p re
g n an
t. S
he w
as ad
m it
te d
fo r
in tr
ac ta
bl e
pa in
, vo
m it
in g,
an d
de hy
dr at
io n.
It w
as n’
t th
e fi
rs t
ti m
e R
ob in
ha d
be en
ad m
it te
d to
th e
ho sp
it al
. S
he ha
d ha
d ep
is od
es w
it h
si m
il ar
sy m
pt om
s fr
om th
e ti
m e
sh e
w as
11 or
12 ye
ar s
ol d.
S he
w ou
ld ha
ve in
te ns
e ab
do m
in al
pa in
an d
w ou
ld st
ar t
vo m
it in
g. S
he w
ou ld
vo m
it 30
ti m
es a
da y.
S he
w ou
ld ge
t de
hy dr
at ed
, o f
co ur
se ,
an d
Sc )
w e
w ou
ld ha
ve to
ad m
it he
r to
th e
ho sp
it al
. T
he fi
rs t
su m
m er
it se
em ed
li ke
sh e
w as
in th
e ho
sp it
al ev
er y
o th
er w
ee k.
T he
do ct
or s
fi na
ll y
de ci
de d
it w
as an
au to
im m
u n e
sy nd
ro m
e th
at th
ey ha
d se
en m
os tl
y in
te en
ag ed
gi rl
s, an
d th
ey ju
st gr
ow ou
t o fi
t. W
e tr
ie d
al le
rg y-
ty pe
tr ea
tm en
ts , w
hi ch
ne ve
r se
em ed
to w
or k,
an d
in th
e en
d th
ey de
ci de
d th
at th
e on
i.y w
ay th
ey co
ul d
tr ea
t it
w as
sy m
pt om
at ic
al ly
.
W h en
sh e
w ou
ld ge
t si
ck sh
e w
ou ld
be ad
m it
te d
to th
e ho
sp it
al an
d gi
ve n
in tr
av en
ou s
fl ui
ds ,
an d
sh e
w ou
ld es
se nt
ia ll
y ta
ke n o th
in g
by m
o u th
un ti
l he
r st
om ac
h se
tt le
d do
w n
an d
sh e
co ul
d to
le ra
te fo
od ag
ai n.
S he
di dn
’t ge
t si
ck be
ca us
e o f
th e
na us
ea ;
sh e
go t
si ck
fr om
th e
pa in
an d
re sp
on de
d to
na rc
ot ic
s. ‘T
he y
w ou
ld gi
ve he
r pr
ed ni
so ne
be ca
us e
o f
th e
al le
rg y
re ac
ti on
, an
d th
ey w
ou ld
hy dr
at e
he r.
A n d
th at
’s w
h at
w e
di d
fo r
se ve
ra l.
ye ar
s. A
s sh
e go
t ol
de r,
th e
ep is
od es
sc ho
ol ,
sh e
w as
on ly
’ g et
ti n g
si ck
tw o
or th
re e
ti m
es a
ye ar
. S
he go
t m
ar ri
ed an
d m
ov ed
aw ay
’ an
d st
ar te
d w
or ki
ng fb
r a
fa m
il y
pr ac
ti ce
d o ct
o r
w ho
pr es
cr ib
ed m
ed ic
at io
n sh
e co
ul d
ta ke
on a
re gu
la r
ba si
s. S
he di
d w
el l
on th
e m
ed ic
at io
n, an
ti sh
e se
em ed
to ha
ve th
in gs
u n d er
co nt
ro l.
T he
n sh
e go
t pr
eg na
nt .
11 cr
m ed
ic at
io n
w as
no t
co m
pa ti
bl e
w it
h p re
g n a n c
so sh
e ha
d to
go of
f it.
B ut
sh e
di d
fi ne
, ev
en af
te r
th at
, un
ti l
sh e
go t
to 28
w ee
ks pr
eg na
nt .
A n d
th en
, m
ay be
be ca
us e
o f
th e
si ze
o f
th e
ut er
us an
ti th
e bo
dy ch
an ge
s, sh
e be
ca m
e si
ck ag
ai n.
B y
th e
ti m
e sh
e w
as 32
w ee
ks pr
eg na
nt ,
R ob
in ha
d lo
st ab
ou t
60 po
un ds
. ‘T
he y’
de ci
de d
to pi
n in
a ce
nt ra
l ve
no us
ca th
et er
, a
ca th
et er
pl ac
ed in
a la
rg e
ve in
in he
r ch
es t,
‘I hi
s le
t he
r ta
ke li
pi ds
a id
to ta
l pa
re nt
er al
n u tr
it io
n (T
P N
), so
sh e
re ce
iv ed
m os
t o f
he r
n u tr
it io
n in
tr av
en ou
sl y.
S he
co n ti
n u ed
to w
or k.
S he
w ou
ld co
m e
ho m
e an
d ho
ok up
he r
lV s;
th ey
w o u ld
ru n
al l
ni gh
t, an
d sh
e w
ou ld
go ba
ck to
w or
k th
e ne
xt da
y. W
h en
ev er
sh e
di d
st ar
t to
ge t
si ck
, sh
e w
ou ld
go to
th e
em er
ge nc
y ro
om .
T he
y w
ou ld
gi ve
he r
so m
e na
rc ot
ic s,
w hi
ch w
as an
is su
e fo
r so
m e
o f
th e
nu rs
es be
ca us
e th
ey di
dn ’t
th in
k sh
e sh
o u ld
ge t
na rc
ot ic
s w
hi le
p re
g n
an t.
D u ri
n g
th e
la st
3 w
ee ks
o f
h er
fi rs
t p
re g
n an
cy sh
e ba
si ca
ll y
q u
it ea
ti ng
an d
li ve
d on
ic e
ch ip
s, be
ca us
e an
yt hi
ng sh
e at
e sh
e th
re w
up .T
he y
de li
ve re
d he
r ea
rl y
at ab
ou t
37 w
ee ks
.J er
ic k,
m y’
gr an
ds on
, w
ei g h ed
6 p o u n d s,
4 ou
nc es
. H
er w
ei g
h t
lo ss
ha dn
’t b o th
er ed
hi m
at al
l. H
e di
d fi
ne .
‘T t’
fl B
e D
ff re
n t
T hi
s T
im e”
R ob
in ta
lk ed
ab ou
t w
an ti
n g
to ha
ve a
li tt
le gi
rl ,
an d
I ke
pt d is
co u r
ag in
g he
r. I
sa id
, “R
o b in
, y
o u
re m
em b
er ho
w si
ck yo
u w
er e.
D o
yo u
re al
ly w
an t
to go
th ro
u g h
th at
ag ai
n? ”
‘T he
n Je
ri ck
ca m
e up
to m
e on
e da
y an
d he
ha d
on a
te e
sh ir
t th
at sa
id ,
“I ’m
th e
bi g
br ot
he r.
I lo
ok ed
at R
ob in
an d
sa id
, “O
h, ho
ne y,
2,
re al
ly ?”
S he
sa id
, “Y
ea h,
M o
m ,
bu t
do n’
t w
or ry
. It
’l l
be d i&
re n t
th is
ti m
e. ”I
sa id
, “ O
ka y.
”l w
as th
ri ll
ed , o f
co ur
se ,
to ha
ve an
o th
er g ra
n d
ch il
d, h
u t]
ce rt
ai nl
y di
dn ’t
w an
t to
se e
he r
in as
m uc
h pa
in as
be fo
re .
A nd
ag ai
n, sh
e di
d w
el l
un ti
l sh
e w
as 26
or 27
w ee
ks al
on g
an d
th en
sh e
be ca
m e
si ck
. R
ob in
s y o u n g e r
si st
er w
as g
et ti
n g
m ar
ri ed
in Ju
ne ,
an d
to w
ar d
th e
en d
of M
a; ;
R ob
in s
do ct
or ,
w ho
w as
al so
th e
do ct
or th
at sh
e w
or ke
d fo
r, w
an te
d to
pu t
in a
pe ri
ph er
al in
tr av
en ou
s c e n
tr al
ca th
et er
(P 1C
C )
ru nn
in g
fr om
an IV
si te
in he
r ar
m to
th e
la rg
e bl
oo d
ve ss
el ab
ov e
th e
he ar
t to
re st
ar t
th e
in tr
av en
ou s
n u tr
it io
n .
R ob
in di
dn ’t
w an
t to
ha ve
a P
1C C
li ne
be ca
us e
sh e
di dn
’t w
an t
it
to sh
ow in
th e
w ed
di ng
pi ct
ur es
. SC
) sh
e m
ad e
hi m
w ai
t un
ti l
th e
w ed
di ng
w as
ov er
, an
d ab
ou t
th e
m id
dl e
o f
Ju ne
th e’
p u t
in th
e P
1C C
li ne
. S
he he
ga n
to in
fu se
th e
T P
N at
n ig
h t
an d
co n ti
n u ed
to w
or k
d u ri
n g
th e
da y,
ju st
as sh
e ha
d do
ne d u ri
n g
he r
fi rs
t pr
eg na
nc y.
S he
ha d
pr ob
ab ly
lo st
40 po
un ds
by th
at ti
m e.
T he
y di
d a
lo t
o f
ul tr
as ou
nd s
to m
ak e
su re
th at
th e
ba by
w as
g ro
w
in g.
W e
fo un
d ou
t it
w as
go in
g to
be a
gi rl
. S
he w
as ju
st th
ri ll
ed .
S he
ha d
he r
bo y
an d
no w
sh e
w as
go in
g to
ha ve
he r
gi rl
, an
d th
is w
ou ld
he th
e en
d o f
it .
S he
w ou
ld n’
t ha
ve to
go th
ro ug
h th
is ag
ai n.
Je ri
ck tu
rn ed
3 on
Ju ly
15 an
d w
e w
en t
to ce
le br
at e
hi s
bi rt
hd ay
. R
ob in
w as
ve ry
si ck
. I
ta lk
ed he
r in
to le
tt in
g m
e ta
ke Je
ri ck
ho m
e w
it h
m e
so th
at th
ey w
o u ld
n t
ha ve
to w
or ry
ab ou
t ch
il dc
ar e
if sh
e ha
d to
go to
th e
ho sp
it al
. So
Je ri
ck ca
m e
ho m
e w
it h
m e.
O n
th e
m or
ni ng
o f
Ju ly
18 R
ob in
ca ll
ed an
d sa
id sh
e ha
d go
ne to
th e
ho sp
it al
. S
he w
as 35
w ee
ks pr
eg na
nt ,
an d
th e
do ct
or w
ho w
as ta
ki ng
ca re
o f
he r
w an
te d
he r
in du
ce d.
H e
ta lk
ed to
th e
pe di
at ri
ci an
, an
d th
e pe
di at
ri ci
an ag
re ed
. li
e sa
id ,
“Y ou
kn ow
, sh
e’ s
35 w
ee ks
. It
’s pr
ob ab
ly ju
st as
sa k
tr th
e ba
by to
be on
th e
ou ts
id e
as it
is on
th e
in si
de ,
as si
ck as
sh e
is no
w .”
R ob
in w
as ex
ci te
d. S
he sa
id , “
M or
n, pa
ck so
m e
ex tr
a cl
ot he
s, be
ca us
e yo
u’ re
go in
g to
st ay
an d
w e’
re go
in g
to ha
ve th
e ha
by .”
W e
w er
e b o th
ex ci
te d.
I st
ar te
d dr
iv in
g to
he r
ho sp
it al
. b u t
w h en
I w
as ab
ou t
ha lf
w ay
th er
e sh
e ca
ll ed
an d
sh e
w as
cr yi
ng .
S he
sa id
th e
O B
do ct
or ,
th e
ob st
et ri
ci an
w ho
w as
su pp
os ed
to in
du ce
he r,
sa id
he w
ou ld
no t
in du
ce he
r be
fo re
sh e
ha d
co m
pl et
ed 37
w ee
ks du
e to
th e
ri sk
to th
e pr
em at
ur e
ba by
.
li e
to ld
R ob
in he
d id
n t
ca re
ho w
m an
y’ ti
m es
sh e
go t
si ck
, th
at sh
e w
ou ld
ha ve
to st
ay in
th e
ho sp
it al
un ti
l sh
e w
as re
ad y’
to be
in du
ce d
at 37
w ee
ks as
th at
w as
be st
fo r
th e
ba by
. W
el l,
th at
m ea
n t
2 m
or e
w ee
ks in
th e
ho sp
it al
, w
it h
o u
tJ er
ic k
. S
he di
dn ’t
ha ve
an y
ex tr
a ti
m e
le ft
to ta
ke of
f fr
om w
or k,
an d
it w
as ju
st de
va st
at in
g fo
r he
r to
fi nd
ou t
th at
th ey
w er
en ’t
go in
g to
de li
ve r
he r
th at
da y.
S om
et hi
ng W
ro ng
I ar
ri ve
d at
th e
ho sp
it al
ab ou
t 1:
00 in
th e
af te
rn oo
n. R
ob in
w as
in th
e sh
ow er
,w hi
ch w
as no
t a
go od
si gn
. H
o t
sh ow
er s
w er
e th
e on
ly th
in g
sh e
ha d
th un
d th
at he
lp ed
re lie
ve th
e pa
in ,
ot he
r th
an na
rc ot
ic s.
S he
w ou
ld ta
ke fo
ur or
fiv e
ho t
sh ow
er s
a da
y w
he ne
ve r
sh e
w as
si ck
.R ob
in ca
m e
ou t
o f
th e
sh ow
er an
d sh
e sa
id ,“
M om
, th
er e’
s so
m et
hi ng
w ro
ng .
I h u n
ev er
yw he
re .
M y
fe et
hu rt
. M
v ha
nd s
hu rt
. E
ve ry
th in
g hu
rt s.
A nd
it st
ar te
d w
he n
th ey
hu ng
th at
ha g
o f
st uf
f th
er e.
” S
he po
in te
d to
a ha
g ha
ng in
g on
th e
IV po
le .T
he on
ly w
ay I
ca n
de sc
ri be
it is
to sa
y th
at it
lo ok
ed lik
e a
m el
te d
ch oc
ol at
e m
il ks
ha ke
, so
rt o f
lik e
a pr
ot ei
n dr
in k.
I lo
ok ed
at it
an d
on ev
er y
co rn
er it
sa id
, “N
ot fo
r IV
U se
”— an
d it
w as
ho ok
ed to
he r
P 1C
C lin
e, w
hi ch
o f
co ur
se is
an IV
. A
nd I
(l id
no t
th in
k to
qu es
ti on
it .
I di
dn ’t
as k
an yt
hi ng
ab ou
t it
.
R ob
in ca
ll ed
th e
nu rs
e an
d as
ke d,
“C an
yo u
te ll
m y
m om
w h at
th e
pl an
is ?”
A nd
th e
nu rs
e sa
id ,
“W el
l, w
e ha
ve st
ar te
d he
r T
P N
an d
w e
ar e
go in
g to
ke ep
he r
in th
e ho
sp it
al un
ti l
sh e’
s 37
w ee
ks an
d w
ea n
he r
of f
th e
na rc
ot ic
s be
ca us
e w
e th
in k
th at
’s w
h at
is w
ro ng
w it
h he
r. S
he is
g et
ti n g
to o
m an
y na
rc ot
ic s.
”
I w
as a
li tt
le du
bi ou
s h u t
I sa
id ,
“O ka
y, if
th at
’s w
h at
w e
ne ed
to do
, th
at ’s
w h at
w e’
ll do
.” B
ut R
ob in
w as
so un
co m
fo rt
ab le
. S
he as
ke d
2
‘T he
nu rs
e ca
m e
in .
I as
ke d
he r,
“H av
e th
ey ch
ec ke
d on
th e
ba by
?” th
e nu
rs e
w hy
sh e
w as
in so
m uc
h pa
in an
d th
e nu
rs e
sa id
, “W
el l,
it’ s
be ca
us e
w e
ar e
no t
gi vi
ng yo
u as
m uc
h pa
in m
ed ic
in e.
Y ou
’r e
ju st
an xi
ou s
an d
yo u
ne ed
to re
la x.
” S
he go
t he
r so
m e
V is
ta ri
l fo
r a n x ie
t A
g ai
n ,
I di
dn ’t
qu es
ti on
it .
I w
en t
al on
g w
it h
th em
.
R ob
in tr
ie d
to re
st .
S he
ju st
h u rt
so m
u ch
, bu
t th
ey w
ou ld
n’ t
gi ve
he r
an y
m or
e pa
in m
ed ic
in e.
S he
ha d
be en
h o o k ed
up to
a fe
ta l
m o
n it
o r
ea rl
ie r
th at
m o rn
in g
an d
th e
st ri
p w
as st
il l
on th
e m
o n
i to
r. I
lo ok
ed at
it ,
an d
fr om
th e
tr ac
in g
it lo
ok ed
li ke
th e
ba by
w as
as le
ep .
It w
as n’
t ve
ry re
ac ti
ve ,
b u t
be ca
us e
R ob
in w
as on
na rc
ot ic
s th
at w
as n’
t su
rp ri
si n g .
‘T hi
s w
as an
o th
er re
as on
th e
nu rs
e ha
d sa
id th
at th
ey w
an te
d to
ke ep
R ob
in in
th e
h o sp
it al
, be
ca us
e th
e ba
by ’s
fe ta
l m
o n it
o r
st ri
p w
as n’
t re
ac ti
ve ,
ev en
th o u g h
it o b v i
ou sl
y w
as n’
t go
in g
to be
if R
o b
in w
as on
n ar
co ti
cs .
B u t
ag ai
n, I
di dn
’t q
u es
ti o
n it
.
‘ f l y
, 1 ,
7 ”
‘ i T
ro u
v e
i. ,o
t to
ri x
iv ie
I ha
d dr
op pe
d Je
ri ck
of f
at da
yc ar
e be
fo re
co m
in g
to th
e ho
sp it
al ,
bu t
I ha
d to
pi ck
hi m
up at
5: 00
p. m
. I
to ld
R ob
in ,
“I ’v
e go
t to
go pi
ck up
Je ri
ck ,
hu t
I’ ll
he ba
ck w
he n
Je re
m y
ge ts
ho m
e fr
om w
or k.
” I
go t
Je ri
ck an
d w
en t
to th
ei r
ho us
e. I
w as
w ai
ti ng
fi rJ
er em
y to
ge t
ho m
e, w
he n
R ob
in ca
ll ed
. S
he sa
id ,“
M om
, I
ne ed
yo u
to co
m e
ba ck
. ‘T
he y’
ve do
ne so
m et
hi ng
w ro
ng .”
I ca
ll ed
Je re
m y
an d
sa id
,” Y
ou ne
ed to
co m
e ho
m e
no w
.T he
y’ ve
do ne
so m
et hi
ng at
th e
ho sp
it al
an d
w e
ne ed
to go
ba ck
th er
e. ”
I go
t to
th e
ho sp
it al
ab ou
t 6:
00 p.
m .W
h en
I w
al ke
d in
th e
ro om
R ob
in w
as on
a he
ar t
m o
n it
o r
an d
sh e
ha d
on a
fa ce
m as
k w
it h
ox yg
en .
S he
lo ok
ed at
m e,
an d
te ar
s ju
st ro
ll ed
do w
n he
r ch
ee ks
. S
he sa
id ,“
M om
, I’
m so
sc ar
ed .”
I sa
id ,
“I t’
ll be
ok ay
.T he
y’ re
go in
g to
ta ke
go od
ca re
o f
yo u.
W e
ju st
ne ed
to ta
ke ca
re o f
yo u.
” B
ut w
he n
I p
u t
m y
ha nd
on he
r ba
ck ,
yo u
co ul
d fe
el an
d he
ar ,w
he ne
ve r
sh e
br ea
th ed
, th
e fl
ui d
th at
w as
in he
r lu
ng s.
S he
sa id
, “Y
es ,
w e
ra n
a fe
ta l
m o n it
o r
st ri
p a
w hi
le ag
o. T
he he
ar t
ra te
w as
15 0.
” B
ut on
th e
m o n it
o r
R ob
in ’s
he ar
t ra
te w
as al
so 15
0. I’
m su
re th
ey w
er e
pi ck
in g
up R
ob in
’s h ea
rt b ea
t ra
th er
th an
th e
ba by
’s .
‘T he
y sh
ou ld
ha ve
ch ec
ke d
R ob
in ’s
pu ls
e to
m ak
e su
re .
B ut
15 0
is a
ve ry
co m
m on
ba by
h ea
rt ra
te ,
an d
th ey
ju st
to o k
it at
fl ic
e va
lu e.
‘T he
O B
d o ct
o r
ca m
e in
ab ou
t th
en .
li e
sa id
, “R
ob in
, I
th in
k th
ey ga
ve yo
u to
o m
uc h
fl ui
d in
th e
em er
ge nc
y ro
om .
W e’
re ju
st go
in g
to gi
ve yo
u so
m e
L as
ix an
d w
e’ ll
ge t
th is
ta ke
n ca
re o
f”
A nd
he le
ft .
T he
nu rs
e w
as st
ill th
er e
w it
h m
e. I
sa id
, “I
s th
at al
l th
ey ’r
e go
in g
to do
? A
re th
ey go
in g
to do
so m
et h in
g el
se ?
S he
lo ok
s te
rr ib
le .”
I di
dn ’t
sa y’
th at
lo u
d en
ou gh
fo r
R ob
in to
he ar
. B
ut sh
e ha
d a
te r
ri bl
e co
lo r.
11 cr
ox i’
ge n
sa tu
ra ti
on w
as 89
. 11
cr h ea
rt ra
te w
as 15
0. S
he w
as ha
vi ng
tr ou
bl e
br ea
th in
g. I
sa id
, “ V
h a t
el se
ar e
yo u
go in
g
to do
?”
T he
nu rs
e sa
id ,
“W e’
ll ge
t th
e L
as ix
. W
e’ ll
ge t
th at
st ar
te d.
”
A b
o u
t th
at ti
m e
R ob
in ’s
d o ct
o r
ca m
e in
, th
e on
e w
ho ’d
be en
ra ki
ng •
ca re
o f
he r
an d
w ho
sh e
w or
ke d
fo r.
H e
ca m
e ov
er ,
an d
he ga
ve he
r •
a hu
g. S
he sa
id ,
“C hi
ef :
yo u’
ve go
t to
fi x
m e.
”
H e
sa id
, “1
w il
l, R
ob in
. I’
ll ta
ke ca
re o f
yo u.
” li
e as
ke d
th e
nu rs
e, “H
ow m
uc h
o f
th at
st uf
f’ di
d sh
e ge
t? ”
I ha
dn ’t
ev en
no ti
ce d
it w
he n
I w
al ke
d in
at 6:
00 p.
m .,
hu t
th e
br ow
n- lo
ok in
g ba
g w
as no
t h an
g in
g on
th e
p. ol
e an
’ m
or e.
S he
ju st
ha d
a tr
an sp
ar en
t sa
li ne
so lu
ti on
ha ng
in g.
‘T he
nu rs
e sh
ow ed
th e
do ct
or on
th e
co m
pu te
r ho
w m
uc h
o f
th e
br ow
n- lo
ok in
g so
lu ti
on sh
e ha
d be
en gi
ve n,
li e
sa id
,“ O
ka yc
” H
e or
de re
d R
ob in
m or
e L
as ix
, an
d he
w an
te d
2 :
he r
to ha
ve B
iP A
P (h
ile ve
l po
si ti
ve ai
rw ay
’ pr
es su
re )
to he
lp im
pr ov
e he
r br
ea th
in g.
So th
e re
sp ir
at or
y te
ch ni
ci an
ca m
e do
w n
an d
ho ok
ed up
th e
B 1P
A P.
S he
st ar
te d
fe el
in g
be tt
er .
H er
ox yg
en sa
tu ra
ti on
ca m
e up
to ar
ou nd
93 %
an d
sh e
fe lt
m or
e co
m th
rt ah
le .
T he
01 3
do ct
or ca
m e
ba ck
in .
H e
sa id
, “L
et ’s
ch ec
k on
th e
ba by
.” H
e li
st en
ed fo
r a
w hi
le an
d he
di dn
’t he
ar an
yt hi
ng .
li e
sa id
, “L
et ’s
ge t
th e
ul tr
as ou
nd .”
H e
lo ok
ed w
it h
th e
ul tr
as ou
nd fo
r a
w hi
le an
d he
di dn
’t sa
y an
yt hi
ng .
I lo
ok ed
at it
an d
I di
dn ’t
se e
th e
ba by
’s he
ar tb
ea t.
I co
ul d
se e
th e
ba by
, be
ca us
e I
ha ve
lo ok
ed at
a lo
t o f
ul tr
as ou
nd s,
hu t
I di
dn ’t
se e
a h ea
rt b ea
t.
H e
sa id
, “W
e ne
ed to
ge t
th e
bi g
ul tr
as ou
nd m
ac hi
ne do
w n
he re
, to
re al
ly ta
ke a
lo ok
.” A
n d
he le
ft .
I w
al ke
d ou
ts id
e th
e ro
om .
fl ie
nu rs
e ca
m e
ou t.
I as
ke d
he r,
“D id
yo u
se e
a he
ar tb
ea t?
”
T he
nu rs
e sa
id ,
“W el
l, yo
u kn
ow ,
it’ s
no t
a ve
ry go
od ul
tr as
ou nd
m ac
hi ne
, It
ju st
ba si
ca ll
y te
ll s
us th
e po
si ti
on o ft
he ba
by , W
e’ re
go in
g to
ge t
th e
bi g
m ac
hi ne
do w
n he
re to
lo ok
ag ai
n. ”
I sa
id ,
“O ka
y. ”
go t
th e
bi g
ul tr
as ou
nd m
ac hi
ne ,
an d
th e
0 8
do ct
or sa
t at
o f
he r
be d
an d
he lo
ok ed
fo r
a w
hi le
. R
ob in
w at
ch ed
th e
an d
th en
sh e
lo ok
ed at
m e
an d
sh e
sa id
, “M
om ,
is sh
e sa
id ,
“Y es
. R
ob in
, I
be li
ev e
sh e
is .”
A nd
I sa
id ,
“B ut
w e
ca n
de al
w it
h th
at ,
R ob
in .
W e
ju st
ne ed
to ta
ke ca
re o f
yo u
ri g h t
no w
.” ‘T
he O
B do
ct or
sa id
, “T
ha t’
s ri
gh t,
R ob
in .
Y ou
ju st
ne ed
to li
st en
to yo
ur m
om .”
A nd
he le
ft .
li e
ne ve
r sa
id an
yt hi
ng ab
ou t
th e
ba by
or th
e la
ck o f
he ar
tb ea
t.
A H
ig h er
L ev
el A
sh or
t ti
m e
la te
r R
ob in
’s do
ct or
ca m
e ba
ck in
. H
e ch
ec ke
d on
R ob
in an
d th
en he
sa id
to m
e, ”I
w an
t to
ta lk
to yo
u ou
t in
th e
ha ll
.”
I w
en t
ou t
in to
th e
ha ll
w it
h hi
m .‘
Th e
O B
do ct
or w
as th
er e.
R ob
in ’s
do ct
or sa
id ,
“I th
in k
w e
ne ed
to ge
t he
r to
a hi
gh er
le ve
l o f
ca re
.W e
ha ve
ca ll
ed L
if el
”l ig
ht an
d w
e’ re
go in
g to
tr an
sf er
he r.
B ut
I th
in k
it’ s
pr ob
ab ly
b et
te r
fo r
us to
in tu
b at
e he
r he
re th
an fi
r th
em to
ha ve
to do
it in
th e
he li
co pt
er .”
In uw
m in
d, I
w as
th in
k in
g , “
O ka
y, w
e lo
st th
e ba
by .\
V e’
ll de
al w
it h
th at
. R
ob in
is ju
st go
in g
to be
in an
o th
er ho
sp it
al fh
r a
fe w
ex tr
a da
ys .
Er ne
ve r
en te
re d
m y
m in
d th
at sh
e w
o u
ld n
t he
ok ay
. It
ju st
ne ve
r oc
cu rr
ed to
m e.
W e
w en
t ba
ck in
an d
he to
ld R
ob in
w h at
th ey
w an
te d
to do
. A
nd sh
e ag
re ed
th at
w e
ne ed
ed to
do so
m et
h in
g di
ff er
en t.
‘T he
y ca
ll ed
an es
th es
ia to
co m
e in
tu b at
e he
r.
A b o u t
th at
ti m
e, he
r hu
sb an
d Je
re m
y ar
ri ve
d. B
ot h
th e
do ct
c rs
w er
e bu
sy an
d I
sa id
, “Y
ou gu
ys w
or k
on R
ob in
an d
m ak
e su
re sh
e’ s
ok ay
I’ ll
go ta
lk to
je re
m c”
I w
en t
ou t
an d
I to
ld hi
m .
I sa
id ,”
je re
m v,
th e
ba by
’s de
ad ,
an d
R ob
in is
so si
ck th
at th
ey ’r
e go
in g
to tr
an sf
er he
r. L
if eF
li g h t
is on
its w
ay ’
an d
th ey
’r e
go in
g to
se nd
he r
ou t.”
I st
av ed
w it
h hi
m a
li tt
le hi
t, an
d th
en he
ad ed
ha ck
to R
ob in
’s r o
o m
.
T he
y st
op pe
d m
e ou
ts id
e th
e do
or an
d sa
id ,
“Y bu
ca n’
t go
in th
er e.
”
I sa
id ,
“‘ ll
at ’s
m y
d au
g h te
r in
th er
e! I
ca n
go w
he re
ve r
I w
an t.
I’ m
go in
g ba
ck in
th er
e. ”
‘T he
y sa
id ,
“N o.
yo u
ca n’
t go
ba ck
in th
er e.
”
I c o
u ld
he ar
th ro
ug h
th e
do or
th at
th ey
’ w
er e
ta lk
in g
ab ou
t hi
ca rh
an d
ep it
ie ph
ri ne
, an
d I
kn ew
th ey
w er
e co
di ng
he r.
T he
he ad
nu rs
e ca
m e
ou t;
I th
in k
sh e
w as
co m
in g
ou t
to ge
t so
m et
hi ng
. I
st op
pe d
he r
an d
sa id
, “Y
ou gu
ys ne
ed to
co m
e ou
t he
re an
d te
ll m
e w
h at
is go
in g
on .
S om
eb od
y ne
ed s
to co
m e
ou t
an d
te ll
m e
no w
.
So th
ey th
e fb
ot m
o n it
o r
de ad
?” I
2.
T he
y to
ok us
do w
n to
a li
tt le
ro om
do w
n th
e ba
ll . T
he y
sa id
, “ S
o m
e bo
dy w
ill co
m e
in an
d ta
lk to
yo u.
”
R ob
in ’s
do ct
or ca
m e
in .
H e
sa id
, “\
‘V el
l, w
e’ ve
ca ll
ed a
ca rd
io lo
gi st
to co
m e
in ,
hu t
he ’s
n o t
in h o u s e ,
li e’
s on
hi s
w ay
in .”
T he
y ha
d pu
t in
a pa
ce m
ak er
. W it
h o u t
th e
pa ce
m ak
er ,
he r
h ea
rt ra
te w
as a
sl ow
30 .
E ve
n w
it h
th e
pa ce
m ak
er ,
th e’
w er
en ’t
g et
ti n g
an y
pe ri
ph er
al pu
ls es
, so
he r
he ar
t w
as no
t p
u m
p in
g en
ou gh
bl oo
d to
he r
br ai
n.
I to
ld hi
m ,
“O ka
y, st
op .
S to
p ri
g h t
no w
. T
h tt
ca n n o t
be ta
lk in
g ab
ou t
on e
o f
m y
gi rl
s th
at w
ay .
Y ou
ne ed
to ge
t ba
ck in
th er
e an
d yo
u ne
ed to
fix he
r, be
ca us
e th
is ca
n n o t
he ha
pp en
in g.
”
li e
le ft
. H
e w
as go
ne fo
r a
fe w
m in
ut es
. lI
e ca
m e
ba ck
in an
d he
op en
ed th
e do
or .
I lo
ok ed
at hi
m an
d I
Ju st
tu rn
ed m
y’ ba
ck on
hi m
.
I sa
id ,
“C an
Y ou
ke ep
he r
al iv
e un
ti l
he r
si st
er s
ge t
he re
to sa
y go
od -b
ye ?”
H e
sa id
, “N
o, I
do n’
t th
in k
I ca
n. ”
I sa
id ,
“I w
an t
to se
e he
r. ”’
T he
v pr
on ou
nc ed
he r
de ad
at 8:
36 p.
m .,
3 da
ys af
te r
Je ri
ck ’s
th ir
d bi
rt hd
ay .
A T
u b
in g
M is
co n n ec
ti o n
T he
nu rs
e ha
d er
ro ne
ou sl
y gi
ve n
R ob
in an
en te
ra l
fe ed
, a
th ic
k m
ix tu
re li
ke a
nu tr
it io
na l
sh ak
e, in
he r
in tr
av en
ou s
P 1C
C li
ne .
E nt
er al
so lu
ti on
is su
it ab
le on
ly fo
r fe
ed in
g vi
a th
e g as
tr o in
te st
in al
tr ac
t, us
ua ll
y th
ro u g h
a fe
ed in
g tu
be .
‘T hi
s er
ro r
ul ti
m at
el y
ca us
ed th
e de
at h
o f
R ob
in an
d th
e ba
by .
T he
or ig
in o f
th e
er ro
r w
a s
a li
tt le
nw st
er io
us .
A ha
g o f
en te
ra l
fe ed
w it
h R
ob in
’s na
m e
on it
ha d
be en
de li
ve re
d to
th e
un it
. T he
de li
ve ry
ca m
e fr
om th
e di
et ar
y d ep
ar tm
en t,
be ca
us e
en te
ra l
fe ed
w as
c o n
si de
re d
a tb
od at
th at
ho sp
it al
an d
w as
di sp
en se
d th
ro u g h
th e
di et
ar y
d ep
ar tm
en t.
T he
to ta
l pa
re nt
er al
so lu
ti on
(T P
N )
th at
R ob
in w
as su
pp os
ed to
ha ve
re ce
iv ed
w as
co ns
id er
ed an
IV m
ed ic
at io
n an
d
w ou
ld ha
ve co
m e
fr om
th e
ho sp
it al
ph ar
m ac
y. T
o co
m pl
ic at
e m
a t
te rs
, th
e ho
sp it
al ha
d ju
st in
tr o d u ce
d a
ne w
co m
p u te
r sy
st em
, an
d
th ey
’ st
ill w
er e
ha nd
— w
ri ti
ng or
de rs
fo r
th e
se cr
et ar
y to
p u t
in to
th e
co m
pu te
r. ‘T
he or
de r
fo r
th e
en te
ra l
fe ed
in g
ba g
w as
ti m
e- st
am p ed
an d
n am
e- st
am p
ed by
th e
u n
it se
cr et
ar y,
b u t
th e
se cr
et ar
y sa
id sh
.e ha
d no
t p u t
th e
or de
r in
. T he
re w
er e
no w
ri tt
en ph
ys ic
ia n
or de
rs fo
r
ei th
er th
e en
te ra
l so
lu ti
on or
th e
T P
N .
T he
ho sp
it al
po li
cy w
as th
at tw
o nu
rs es
ch ec
k th
e la
be l
an d
th e
in gr
ed ie
nt s
ag ai
ns t
th e
or de
r be
fo re
it w
as gi
ve n
to th
e pa
ti en
t. B
u t
in th
is ca
se th
er e
w as
no or
de r,
an d
th e
nu rs
e di
d no
t ha
ve a
se co
nd
nu rs
e ch
ec k
it w
it h
he r
an d
di d
no t
sc an
th e
ba r
co de
on th
e m
e d
i
ca ti
on .
T he
nu rs
e kn
ew th
at th
e pl
an w
as fo
r R
ob in
to ge
t T
P N
, so
th at
’s w
h at
sh e
as su
m ed
th e
ha g
w as
, ev
en th
o u g h
it lo
ok ed
n o th
in g
li ke
T P
N .
T yp
ic al
ly ,
a ba
g o f
en te
ra l
so lu
ti on
co m
es fr
om th
e m
an u fa
ct u re
r
at ta
ch ed
to a
tu be
th at
w il
l on
ly fi
t a
fe ed
in g
tu be
, no
t an
IV .
B u t
n o t
al l
m an
uf li
ct ur
er s
m ak
e it
th at
w ay
. In
R ob
in ’s
ca se
, th
e ba
g
ca m
e w
it h
o u
t tu
bi ng
. So
th e
nu rs
e go
t so
m e
TV tu
b in
g of
f th
e sh
el t
sp ik
ed th
e ba
g w
it h
th e
tu bi
ng ,
an d
p u t
th e
tu b in
g on
an IV
in fu
si on
pu m
p. T
he en
te ra
l so
lu ti
on w
as to
o th
ic k
to ru
n on
its ow
n,
so th
e nu
rs e
se t
th e
in fu
si on
p u m
p to
20 0
m L
an h o u r
an d
c o n
ne ct
ed it
to R
ob in
’s P
1C C
li ne
. A
P 1C
C li
ne si
ts ri
g h t
at th
e ar
ch
o f
th e
ao rt
a, so
th e
fe ed
in g
w as
d u
m p
in g
ri g h t
in to
he r
he ar
t, an
d
it ha
d su
ch a
h ig
h fa
t co
n te
n t
th at
ev er
y th
in g
w as
cl og
gi ng
u p
.
T ha
t’ s
w hy
he r
fe et
h u
rt so
m uc
h, be
ca us
e al
l th
e li
tt le
ve ss
el s
in
he r
fe et
— ev
er yt
hi ng
— w
er e
Ju st
cl og
gi ng
up w
it h
fa t.
‘i be
po li
cy at
th e
ho sp
it al
w as
th at
th e
n u tr
it io
n is
t w
ou ld
se e
ev en
’
p at
ie n
t be
fo re
th e
pa ti
en ts
w er
e st
ar te
d on
T P
N .
T he
n u tr
it io
n is
t
w as
go in
g th
ro u g h
th e
ch ar
ts an
d th
e nu
rs e
sa id
, “\
‘V e’
ve go
t th
e
2 11
T P
N st
ar te
d. ”
T hi
s in
it se
lf w
as a
po li
cy vi
ol at
io n.
T he
n u tr
it io
n is
t sa
id , “
N o,
sh e’
s no
t on
T P
N ;
th er
e’ s
no or
de r b
r it
.” It
w as
th en
th at
th ey
no ti
ce d
th e
m is
ta ke
. ‘T
he en
te ra
l fe
ed s
w er
e st
ar te
d at
11 :0
0 a.
m .
an d
th ey
w er
e st
op pe
d ar
ou nd
5: 00
p. m
. T
he nu
rs e
ne ve
r re
a l
iz ed
th er
e w
as an
yt hi
ng w
ro ng
un ti
l th
at m
o m
en t.
C on
cl us
io n
‘T he
nu rs
e lo
st he
r jo
b at
th e
ho sp
it al
an d
su rr
en de
re d
he r
li ce
ns e
un de
r a
pl ea
ag re
em en
t th
at al
lo w
ed he
r li
ce ns
e to
be re
in st
at ed
af te
r 8
m on
th s.
W h en
sh e
go t
he r
li ce
ns e
ba ck
, sh
e w
en t
to w
or k
fb r
th e
O B
d o ct
o r
in vo
lv ed
in R
ob in
’s ca
se .
T he
ho sp
it al
ad m
in is
tr at
io n
st ar
te d
us in
g th
e cl
os ed
tu b in
g sy
st em
so nu
rs es
di d
no t
ha ve
to at
ta ch
th e
tu bi
ng ,
an d
th ey
m ad
e en
te ra
l fe
ed in
gs th
e re
sp on
si bi
li ty
o f
th e
ph ar
m ac
y ra
th er
th an
th e
di et
ar y
d ep
ar tm
en t,
so th
at a
li ce
ns ed
he al
th ca
re pr
of es
si on
al w
ou ld
he ch
ec ki
ng th
e or
de rs
, T
he y
al so
di d
a lo
t o f
ed uc
at io
n to
tr y
to m
ak e
th ei
r nu
rs es
aw ar
e o f
tu b in
g m
is co
nn ec
ti on
s.
I st
ar te
d ta
lk in
g ab
ou t
tu b in
g m
is co
nn ec
ti on
s to
ev er
yo ne
I co
ul d
ge t
to li
st en
. I
ha ve
be en
pa rt
o f
an in
te rn
at io
na l
gr ou
p w
or ki
ng on
ne w
st an
da rd
s, b
u t
ch an
ge is
co m
in g
m uc
h m
or e
sl ow
ly th
an I
w ou
ld lik
e. A
s a
nu rs
e, I
ha ve
ch an
ge d
m y
pr ac
ti ce
ab ou
t pa
ti en
ts an
d fa
m il
ie s
as ki
ng qu
es ti
on s.
I kn
ow th
at so
m et
im es
it ca
n fe
el as
th ou
gh fa
m il
ie s
ar e
qu es
ti on
in g
yo ur
ab il
it y
an d
au th
or it
y. B
ut if
th er
e is
so m
et hi
ng th
at do
es n’
t lo
ok ri
gh t,
fa m
il ie
s sh
ou ld
as k
th e
qu es
ti on
. If
th e
nu rs
e se
es so
m et
h in
g th
at do
es n’
t lo
ok ri
gh t,
th e
nu rs
e sh
ou ld
qu es
ti on
it . If
yo u
do n’
t ge
t a
go od
an sw
er ,
qu es
ti on
it ag
ai n.
K ee
p qu
es ti
on in
g un
ti l
yo u
ge t
a re
so lu
ti on
. I
w il
l go
to m
’v gr
av e
w is
hi ng
th at
I ha
d do
ne th
at fo
r R
ob in
an d
A dd
is on
.
C as
e D
is cu
ss io
n D
el iv
er in
g m
o d er
n h ea
lt h ca
re re
q u ir
es m
an y
tu b
in g
co n n ec
ti o n s
th at
ca n
le ad
to er
ro rs
w it
h m
ed ic
al tu
b in
g or
ca th
et er
s. ‘T
hi s
p ro
b le
m ha
s b ee
n re
co g n iz
ed si
nc e
th e
19 70
s. T
he in
te rc
h an
g e
ab le
L u
er lo
ck us
ed in
th e
co n
n ec
ti o
n o f
m ed
ic al
co m
p o
n en
ts
an ti
ac ce
ss or
ie s
ha s
al lo
w ed
fo r
m an
y m
is co
n n ec
ti o n s
ev er
y ye
ar ,
n o
t ju
st o f
IV s,
b u t
al so
o th
er de
vi ce
s, in
cl u
d in
g b lo
o d
pr es
su re
cu ff
s an
d en
d o
tr ac
h ea
l tu
b es
(G u
en te
r et
al .,
20 08
; U
.S .
F oo
d an
d
D ru
g A
d m
in is
tr at
io n ,
2 0 1 2 ).
E x
p er
ts be
li ev
e th
e on
ly re
al so
lu
ti o n
is th
e re
d es
ig n
o f
tu b
in g
co n
n ec
ti o
n s
to el
im in
at e
th e
p o
s
si bi
li ty
o f
co n n ec
ti o
n s
b et
w ee
n in
co m
p at
ib le
sy st
em s
(V oc
kl ev
,
2 0 1 1 ).
O f
th e
m an
y co
nn ec
ti on
er ro
rs th
at oc
cu r,
th e
m is
co nn
ec ti
on o f
an
en te
ra l
fe ed
in g
sy st
em w
it h
an IV
tu be
is es
pe ci
al ly
fe ar
ed be
ca us
e
th e
re su
lt in
g in
tr o d u ct
io n
o f
hi gh
— fa
t so
lu ti
on in
to th
e bl
oo ds
tr ea
m
is n o t
re ve
rs ib
le an
d th
e ou
tc om
e fo
r th
e p at
ie n t
is li
ke ly
to be
de at
h.
L ik
e o th
er tu
b in
g m
is co
nn ec
ti on
s, en
te ra
l m
is co
nn ec
ti on
s ar
e us
u—
al l’
th e
re su
lt o f
nu rs
in g
er ro
r, an
d th
e le
ga l
an d
pr of
es si
on al
c o n
se qu
en ce
s fo
r nu
rs es
ca n
he se
ve re
, as
th ey
w er
e fo
r R
ob in
’s nu
rs e.
R es
ea rc
he rs
w ho
st ud
y tu
b in
g m
is co
nn ec
ti on
s, ho
w ev
er ,
vi ew
th em
as pr
im ar
il y
a hu
m an
fa ct
or s
pr ob
le m
, an
un co
ns ci
ou s
sl ip
th at
oc cu
rs as
th e
p ra
ct it
io n er
au to
m at
ic al
ly pe
rf or
m s
a ro
ut in
e ta
sk
(S im
m on
s &
G ra
ve s,
20 08
). H
u m
an fl
ic to
rs ,
or h u m
an fa
ct or
s e n g i
ne er
in g,
is “t
he di
sc ip
li ne
th at
at te
m p ts
to id
e n
ti ’
an d
ad dr
es s
sa fe
ty
pr ob
le m
s th
at ar
is e
du e
to th
e in
te ra
ct io
n be
tw ee
n pe
op le
, te
ch n o l
og y,
an d
w or
k en
vi ro
nm en
ts ”
(A ge
nc y
fo r
H ea
lt h ca
re R
es ea
rc h
an d
Q ua
li ty
, 20
12 ).
T he
ac tu
al hi
st or
ic al
fr eq
ue nc
y o f
en te
ra l
tu b in
g m
is co
n n
ec ti
o n
s is
no t
kn ow
n, h u t
a 20
11 re
vi ew
o f
th e
li te
ra tu
re sh
ow ed
m or
e th
an
11 6
ca se
s o fe
n te
ra l
m is
co nn
ec ti
on d o cu
m en
te d
in m
ed ic
al jo
u rn
al s
(S im
m o n s,
S vm
es ,
G u en
te r,
& G
ra ve
s, 20
11 ).
A n
in te
rn at
io n al
co ll
ab or
at io
n, in
w hi
ch R
ob in
L ow
e’ s
m o th
er G
le n d a
is in
cl ud
ed ,
ha s
be en
un de
rw ay
fo r
m an
y ye
ar s
to de
ve lo
p In
te rn
at io
n al
S ta
n d
ar d
O rg
an iz
at io
n (I
S O
) st
an da
rd s
fb r
m an
uf ac
tu re
rs o f
tu b in
g c o n
ne ct
or s.
P ar
tl y
in re
co gn
it io
n o f
th e
se ri
ou sn
es s
o f
th e
pr ob
le m
, th
e
fi rs
t co
nn ec
to rs
to be
pr od
uc ed
u n d er
th e
re vi
se d
st an
da rd
s ar
e pa
rt
o f
a ne
w en
te ra
l fe
ed in
g sy
st em
th at
ca n n o t
he co
nn ec
te d
to
2
in co
m pa
ti bl
e de
li ve
ry sy
st em
s li
ke in
tr av
en ou
s tu
bi ng
. T
he ch
an ge
to th
e ne
w st
an da
rd s
is ta
ki ng
pl ac
e in
ph as
es ,
w it
h tr
an si
ti on
al co
nn ec
to rs
‘a va
ila bl
e so
th at
fa ci
li ti
es ca
n co
nt in
ue to
us e
ex is
ti ng
st oc
ks o f
tu bi
ng .
U se
o f
th e
ne w
co nn
ec to
rs w
il l
no t
be m
an d at
o ry
in an
y A
m er
ic an
st at
e ex
ce pt
C al
if or
ni a,
al th
ou gh
in te
rc ha
ng ea
bl e
co nn
ec to
rs w
il l
gr ad
ua ll
y ce
as e
to be
av ai
la bl
e as
m an
uf hc
tu re
rs ad
o p t
th e
re vi
se d
IS O
st an
da rd
s (G
lo ba
l E
n te
ra l
D ev
ic e
S up
pl ie
r A
ss oc
ia ti
on ,
20 14
; T
he Jo
in t
C o m
m is
si o n ,
20 14
).
Q ue
st io
ns 1.
D is
cu ss
th e
ch ai
n o f
ev en
ts an
d m
is ta
ke s
th at
le d
to th
e de
at h
o f
R ob
in an
d he
r ba
by .
A t
w h
at p
o in
t co
ul d
th e
p en
d in
g di
sa st
er ha
ve be
en st
op pe
d? W
h at
pr oc
es se
s co
ul d
be p u t
in pl
ac e
to pr
ev en
t su
ch an
ev en
t fr
om oc
cu rr
in g?
2. T
he m
os t
si gn
if ic
an t
ch an
ge th
at th
e ho
sp it
al m
ad e
w as
to st
op bu
yi ng
en te
ra l
fe ed
in g
so lu
ti on
th at
ca m
e w
it h o u t
th e
tu b in
g at
ta ch
ed .
R es
ea rc
h hu
m an
fa ct
or s
th eo
ry an
d di
sc us
s th
e hu
m an
fh ct
or s
is su
es th
at ar
is e
w it
h tu
b in
g m
is co
nn ec
ti on
s. H
o w
ca n
k rc
in g
fu nc
ti on
s li
ke th
e an
ti ci
pa te
d m
ov e
to sp
ec ia
li ze
d co
nn ec
to rs
im pr
ov e
th e
si tu
at io
n?
3. G
le n d a
R od
ge rs
bl am
es he
rs el
f fo
r no
t as
ki ng
m or
e qu
es ti
on s
w he
n he
r d
au g h
te r
w as
in th
e ho
sp it
al .
S he
fe el
s th
at ,
as an
ex pe
ri en
ce d
ob st
et ri
ca l
nu rs
e, sh
e sh
ou ld
ha ve
ca ug
ht w
ha t
w as
go in
g on
an d
be en
ab le
to p
u t
a st
op to
it .
Y et
st or
ie s
o f
he al
th ca
re pr
of es
si on
al s
be in
g un
ab le
to st
op ad
ve rs
e ev
en ts
fr om
h ap
p en
in g
to th
ei r
ow n
fa m
il y
m em
be rs
ar e
co m
m on
. W
h y
do yo
u th
in k
th at
he al
th ca
re pr
of es
si on
al s
m ay
fe el
he lp
le ss
to pr
ev en
t er
ro rs
w he
n th
ey be
co m
e a
p at
ie n
t or
ha ve
a fa
m il
y m
em be
r w
ho is
a pa
ti en
t?
4. R
es ea
rc h
th e
co nc
ep t
of ju
s t
c u
lt u
re ,
an d
di sc
us s
ho w
yo u
th in
k it
ap pl
ie s
in th
is ca
se .
W h at
sh ou
ld th
e co
ns eq
ue nc
es ha
ve be
en fo
r th
e nu
rs e
w ho
ca us
ed th
e tu
b in
g in
is co
nn ec
ti on
?
5. A
s th
e ro
ll ou
t o f
ne w
tu b in
g co
n n ec
to r
st an
da rd
s be
ga n,
th c
A m
er ic
an ac
cr ed
it in
g ag
en cy
‘T he
jo in
t C
om m
is si
on is
su ed
S en
ti ne
l E
ve nt
A le
rt N
o. 53
to he
lp he
al th
ca re
fi tc
il it
ie s
de al
w it
h th
e tr
an si
ti on
. X
V hv
do yo
u th
in k
‘T he
Jo in
t C
om m
is si
on co
n si
d er
ed th
is to
be ne
ce ss
ar y?
V h a t
u n in
te n d ed
co ns
eq ue
nc es
sh o u ld
he al
rh ca
re pr
of es
si on
al s
he vi
gi la
nt fo
r w
h en
ch an
g es
ta k
e p la
ce in
p ra
ct ic
c Sa
nd te
ch no
lo gy
?
6. \V
h ic
h o f
th e
co re
co m
pe te
nc ie
s fo
r he
al th
pr of
es si
on s
ar e
m o
st re
le v
an t
tb r
th is
ca se
? \V
hy ?
R ef
er en
ce s
A ge
nc y
fo r
le al
th ca
re R
es ea
rc h
an d
Q ya
li tv
. (2
01 2)
. H
u m
an fa
ct or
s e n g in
e e r in
g .
A l
1R Q
P S
N et
. A
va ila
bl e
at :
ht tp
:/ /w
w w
.p sn
et .a
hr q.
go v
/p r i m
e r .a
s p x ? p r im
e r l
1) =
20 .
C u e n te
r ,
P. ,
H ic
ks ,
R .,
S im
m on
s, D
., C
ro w
le v,
J. ,
C ro
te au
, R
., G
os ne
li ,
C .,
P ra
tt ,
N .
C .,
& V
àn de
rv ee
n, T
. W
. (2
00 8)
. E
nr er
al fe
ed in
g m
is e o n n e e
ti o
n s :
A c o n s o
r ti
u m
p o s it
io n
s ta
te m
e n t.
jo in
t C
o m
m is
si o
n jo
in -n
a! on
P ia
/i iv
a n
d P
a ti
e n
t Sg
/’ ty
, .3
4( 5)
, 28
5— 29
2. G
lo ba
l F
nt er
al l)
ev ie
e S
up pl
ie r
A ss
oc ia
ti on
. (2
01 4)
. N
ew E
N F
’i t
C on
— ne
ct or
s 1)
ue in
U S
, C
an ad
a, P
u er
to R
ic o
in 20
14 ;
E u
ro p
e an
d o th
er m
ar ke
ts an
ti ci
pa te
to be
gi n
tr an
si ti
o n
in 20
15 .
S ta
y C
o n n ec
te d
20 14
. A
va il
ab le
at :
h tt
p :/
/w w
w .s
ta y eo
n n ec
te d 2 0 1 4 .o
rg lg
et —
re ad
h tm
l S
im m
on s,
I) .,
& G
ra ve
s, K
. (2
00 8)
. ‘]
). ih
in g
m is
co nn
ee ti
on s—
a sy
st em
s E
til ur
e w
it h
h u
m an
fa ct
or s:
L es
so ns
fo r
nu rs
in g
pr ac
ti ce
. U
i’o io
gi c
2 V
n rv
in ,
2X (6
). 46
0— 46
4. S
im m
on s,
I) .,
S vi
ne s,
L .,
G ue
nr er
. P
. &
G ra
ve s,
K .
(2 01
1) .
T u b in
g m
is— co
nn ec
ti on
s: N
o rm
al iz
at io
n ot
de vi
an ce
. N
ut ri
ti on
in C
li ni
ca lP
ra ct
ic e.
26 (3
), 28
6— 29
3. T
he Jo
in t
C o
m m
is si
o n
. (2
01 4,
A u
g u
st 20
). M
an ag
in g
ri sk
d u ri
n g
tr a n
si to
n
to ne
w IS
o tu
b in
g co
n n ec
to r
st an
da rd
s. S
en ti
ne l
E ve
nt A
le rt
5 1
.\ .v
ai la
b le
at :
h tt
p :/
/w w
w .j
o in
tc o
m m
is si
o n
.o rg
/s ea
_ ss
u e_
_ 5
3 i
U .S
. F
oo d
an d
1) ru
g A
d m
in is
tr at
io n .
(2 01
2) .
T u b in
g an
d L
u er
m is
co n—
ne ct
io ns
: P
re ve
nt in
g da
ng er
ou s
m ed
ic al
er ro
rs .
A va
il ab
le at
: h tt
p :/
! w
w w
.f d a.
g o v /\
le d ic
al D
ev ic
es /S
ak n ’/
A lc
rt sa
n d N
o ti
ce s/
l’ u b in
g an
d —
L ue
rM is
co n n ec
ti o
n s/
d et
au lr
.h tn
t V
oc kl
ev ,
N I.
(2 01
1) .
[) an
g er
o u
s co
nn ec
ti on
s: Il
ea lr
hc ar
e co
m m
u n
it y
ta ck
le s
tu bi
ng ri
sk s.
B io
m ed
ic al
In st
ru m
en ta
ti on
& fl
’c hn
ol og
y, 45
(6 ),
42 6—
42 8,
43 0—
42 2,
43 4.
4 4
2 4