Abstract
A medication error caused a near fatal cardiac arrest in a previously healthy patient undergoing elective surgery. Inadvertent epinephrine injection induced ventricular dysrhythmias, hypertension, hypotension and pulmonary oedema. The case was investigated using critical-incident technique and was reviewed by the Risk Management Team of the Department of Anaesthesia. The purpose of this report is to present the recommendations resulting from the investigation. These include: improved resident training in intravenous drug management, the use of anaesthetic drug ampoules with distinct labels, and the development of a standardized colour code system for labels on anaesthetic drug ampoules. Furthermore, it is recommended that all anaesthetic drug errors be reported to the Canadian agencies responsible for drug packaging in order to identify patterns in anaesthetic drug errors, and to facilitate the implementation of effective drug identification systems.
Résumé
Pendant une opération non urgente, une erreur de médicament provoque un arrêt cardiaque chez un patient non taré. De l’épinéphrine injectée par mégarde provoque des dysrythmies ventriculaires, de l’hypertension, de l’hypotension, et de l’oedème pulmonaire. Cet accident fait l’objet d’une investigation par la technique de l’incident critique et est révisé par l’équipe de gestion du risque de département d’anesthésie. Ce rapport expose les recommandations qui découlent de cette investigation. Ils comprennent l’amélioration de la formation des résidents au regard de la manipulation des préparations intraveineuses, l’utilisation d’ampoules étiquetées distinctivement et l’élaboration d’un code de couleur standard pour les étiquettes de préparation anesthésiques. On recommande aussi que toutes les erreurs de drogues anesthésiques soient rapportée aux organismes canadiens responsables de l’emballage des drogues de façon à identifier la tendance des erreurs médicamenteuses en anesthésie et faciliter l’implantation de systèmes d’identification réellement efficaces.
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Orser, B.A., Oxorn, D.C. An anaesthetic drug error: minimizing the risk. Can J Anaesth 41, 120–124 (1994). https://doi.org/10.1007/BF03009804
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DOI: https://doi.org/10.1007/BF03009804