General anesthesia complicated by unexpected hypertension and tachycardia

Reich, David L.; Bucek, John; Wolf, Nelson M.; Klumpe, David B.; Cullen, David J.

doi:10.1016/1053-0770(92)90157-3

Cited by 3 publications

(1 citation statement)

References 24 publications

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“…For example, a recent Dateline report reviewed the case of Ben Kolb, a seven‐year‐old boy in Florida who died as the direct result of receiving local adrena‐line instead of lidocaine with epinephrine during administration of a local anesthetic for ear surgery. Other examples of medication or solution mishaps include using the incorrect strength of lidocaine, 4 administering chlorhexidine gluconate intravenously, 5 injecting formaldehyde during cosmetic blepharoplasty, 6 and infusing dobutamine instead of metocurine 7 …”

Section: Medication Errors In the Operating Roommentioning

confidence: 99%

Wake‐up call—standardization is crucial to eliminating medication errors

Beyea¹

2002

AORN Journal

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Section: Medication Errors In the Operating Roommentioning

confidence: 99%

Wake‐up call—standardization is crucial to eliminating medication errors

Beyea¹

2002

AORN Journal

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An anaesthetic drug error: minimizing the risk

Orser

Oxorn

1994

Can J Anaesth

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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.

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High Stakes and High Risk

Martinez

Thompson

Errett

et al. 2011

Anesthesia &Amp; Analgesia

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Cardiac surgery is a high-risk procedure performed by a multidisciplinary team using complex tools and technologies. Efforts to improve cardiac surgery safety have been ongoing for more than a decade, yet the literature provides little guidance regarding best practices for identifying errors and improving patient safety. This focused review of the literature was undertaken as part of the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems), a multifaceted effort supported by the Society of Cardiovascular Anesthesiologists Foundation to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. Hazards were defined as anything that posed a potential or real risk to the patient, including errors, near misses, and adverse events. Of the 1438 articles identified for title review, 390 underwent full abstract screening, and 69 underwent full article review, which in turn yielded 55 meeting the inclusion criteria for this review. Two key themes emerged. First, studies were predominantly reactive (responding to an event or report) instead of proactive (using prospective designs such as self-assessments and external reviewers, etc.) and very few tested interventions. Second, minor events were predictive of major problems: multiple, often minor, deviations from normal procedures caused a cascade effect, resulting in major distractions that ultimately led to major events. This review fills an important gap in the literature on cardiac surgery safety, that of systematically identifying and categorizing known hazards according to their primary systemic contributor (or contributors). We conclude with recommendations for improving patient outcomes by building a culture of safety, promoting transparency, standardizing training, increasing teamwork, and monitoring performance. Finally, there is an urgent need for studies that evaluate interventions to mitigate the inherent risks of cardiac surgery.

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General anesthesia complicated by unexpected hypertension and tachycardia

Cited by 3 publications

References 24 publications

Wake‐up call—standardization is crucial to eliminating medication errors

Wake‐up call—standardization is crucial to eliminating medication errors

An anaesthetic drug error: minimizing the risk

High Stakes and High Risk

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