Failure to Act: Tubing Misconnections in the United States

摘要

My 24-year-old daughter was 35 weeks pregnant when she was hospitalized for vomiting and dehydration. A bag of ready-to-hang enteral feeding was brought to the floor, and the nurse, assuming it was total parenteral nutrition, pulled regular intravenous tubing from floor stock, spiked the bag, and started the infusion of tube feeding through the patient's peripherally inserted central catheter line. My daughter's fetus died-and then my daughter, after several hours of excruciating pain.