Donoghue E R, Lifschultz B D
J Forensic Sci. 1984 Oct;29(4):1225-8.
A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the child's stomach following surgery.
一名九个月大的女孩曾成功接受食管闭锁手术，在输液泵被误接到用作胃造瘘管的弗利氏导尿管的球囊端口时，发生了胃破裂。当在引流端口插入一个透明塑料转接器以连接泵管时，导管的球囊端口和引流端口在外观和触感上极为相似。导致此次事故的其他因素包括连接时照明不佳、输液泵阻塞警报在压力低到足以防止损伤时未启动，以及手术后孩子胃的尺寸减小。
