Classic cases revisited – Death of a nurse and the anatomy of error

Abstract

The tragic case of Mayra Cabrera who died as a result of wrong route drug administration is notable as it was the first time a verdict of unlawful killing was recorded against an NHS Trust. Error within medicine is a significant cause of patient morbidity and mortality. We explore the costs of error, the dynamics of error causation, the role of both the individual and institution in accountability for error, as well as transferrable lessons from other industries to reduce error.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: A scoping review

“…Of the seven patients who did not receive lipid administration [38, 46-50], ve women with LAST symptoms after post-caesarean TAP block recovered without neurological sequelae [38,46,50]; one of these patients recovered from symptoms after 3 hours [38], and for the remaining four [46], the time to recovery was not stated. Another two women who did not receive lipids for intravenous bupivacaine-induced cardiac arrest died despite resuscitation efforts [47][48][49]. None of the cases reported adverse events following the lipid emulsion administration.…”

“…Of the ve reported cases of the patients with mild toxicity, three received no treatment [50]: one received a colloidal infusion (500 ml; a lipid was prepared but not administered as symptoms improved) [38]; whereas another patient received anticonvulsants at the onset of seizure with no lipid therapy. In two publicly available cases of medication errors of intravascular injection of bupivacaine, patients received resuscitation with advanced cardiovascular life support for the rapidly progressed cardiovascular collapse [47][48][49]. One of these cases occurred after vaginal birth [48,49] and the other during labour, resulting in an emergency caesarean section [47].…”

“…LAST symptoms resolved in all patients who received intravenous lipid emulsion, and no adverse events were observed or reported. There was a notable difference in clinical outcomes in three cases where anaesthetics were mistakenly administered intravenously; one woman receiving lipids with conventional resuscitation survived [36], and two women died with conventional resuscitation alone [47,49]. Because these results are based on case reports and there is no comparison group from the same population, it is impossible to assess whether the favourable outcome resulted from lipid emulsion administration.…”

“…Alternatively, the results could be due to publication bias, to which case reports are prone, where positive (indicating bene cial or harmful effects) ndings are more likely to be reported than negative ndings [62]. Furthermore, medication errors are subject to underreporting because of fear of blame and liability [49,63], making it di cult to assess the effectiveness and safety of lipid emulsions in these case reports.…”

In the preparation and administration of intravenous medicines, what are the best practice standards that healthcare professionals need to follow to ensure patient safety? Protocol for a systematic review.

“…Intravenous therapy and medicines (IVTM) safety can impact greatly on patient care. High profile medication errors have directly led to guidance being developed, as well as landmark legal rulings, both resulting in widespread changes to practice 7 .…”