A big share of the blame falls on device manufacturers who need to re-design tubing so that it only fits where it is supposed to go.

What makes that job harder and more expensive for the manufacturers is the failure of an international committee to quickly establish uniform designs.

State and local hospitals have made some progress on their own since the high-profile death of a Fitchburg teenager at St. Mary 's Hospital in Madison two years ago. But the risk of another deadly mistake is still too great and demands more aggressive action.

For example, hospitals in Wisconsin and Madison continue to use different colors for drug warning labels and patient wristbands, creating potential confusion when patients are transferred from one institution to another.

The Wisconsin Hospital Association has wisely asked its members to standardize color codes for wristbands. Yet too many hospitals are finding excuses to avoid or delay standardizing colors for drug labels.

UW Hospital and Madison 's Veterans Hospital put yellow warning stickers on epidural bags to warn staff that the medication should be given near the spine -- not in the arm. But over at Meriter and St. Mary 's, yellow stickers signify just the opposite. They are placed on drugs that should be given in the arm.

Using the same colors for the same warnings statewide will require careful training and reinforcement for staff at institutions that have to change. Yet uniform colors are the best way to avoid needless harm in the long run.

It was two years ago this month that 16-year-old Jasmine Gant died while giving birth at St. Mary 's Hospital. A nurse mistakenly delivered a spinal drug into Gant 's arm. The nurse mistakenly thought the medicine was penicillin for a strep infection. The nurse didn 't notice a pink warning label, among other oversights. And the tubing fit snugly into the girl 's I.V. even though the spinal drug should never be delivered into the arm.

Sincere regret, a suspended license and legal settlement for Gant 's surviving baby aren 't enough. The medical community needs to standardize its coding procedures and redesign tubes so they can 't go where they shouldn 't.

Madison is lucky to have medical institutions that provide high-quality care to the vast majority of patients. Since Gant 's death, local hospitals have saved countless lives without any major patient-safety violations.

Yet the threat of another deadly mix-up -- one that is easily preventable -- must be further minimized.