A fatal human error that topped the tragedy

http://www.elpais.com/articulo/madrid/error/humano/fatal/remato/tragedia/elpepiespmad/20101109elpmad_8/Tes

A fatal human error that topped the tragedy E. G. S. - Madrid - 09/11/2010
It was his first day. Nine in the evening, about to complete the shift. He had dedicated to helping his two companions and become familiar with a new and highly specialized unit, the neonatal ICU of the hospital Gregorio Maranon. Then came an emergency. A premature baby in hospital worsened and he was transferred to ICU. The novice nurse of 22 years but experienced several months in other units, did not address the new patient. I attended the doctor and two nurses expert, as he relates the preliminary report made public Inspection Ministry of Health.
It was time to feed the two babies, one of them was Ryan, born by Caesarean section one day before the death of his mother, Delilah, the first fatality of influenza A-admitted. The assistant would do, but you are asked to help with the emergency. The novice nurse "provides" the report said. The first baby properly administered enteral nutrition. Ryan is wrong. Instead of connecting the tube to nasogastric tubes, which made the vein. An hour and a quarter later, when he had been scheduled dose, sounded the warning of the bomb. A night shift nurse noticed the error.
And could not save the baby. Even thought to give an exchange transfusion (blood cleansing), but it was very serious. He died at 11.30 am. The report concludes with the recommendation to install "technical mechanisms to prevent compatibility" on products that are administered by different routes.