Inadvertent Epidural Administration of Potassium Chloride A Case Report

Tessler, Michael J.; White, I. W. C.; Nauger-Colville, M. A.; Biehl, Diane R.

doi:10.1097/00132582-198907000-00058

Cited by 11 publications

(20 citation statements)

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“…7 Indeed, anesthetic drug errors have been reported for every aspect of anesthetic-related care. [8][9][10][11] The current study arose from the recommendations resulting from the risk-management analysis of a nearfatal anesthetic drug error. 12 The error involved the administration of epinephrine instead of glycopyrrolate.…”

Section: Medication Errors In Anesthetic Practice: a Survey Of 687 Prmentioning

confidence: 99%

Medication errors in anesthetic practice: a survey of 687 practitioners

Orser

Chen

Yee

2001

Can J Anesth/J Can Anesth

169

143

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GENERAL ANESTHESIA 139 Purpose: The objectives of this study were to determine: 1) if anesthesiologists had experienced a medication error and 2) to identify causal factors. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated. Methods: A self-reporting survey was mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Respondents provided free-text descriptions of medication errors and answered fixed response questions. Results: Surveys from 687 anesthesiologists (30% response rate) revealed that 85% of the participants had experienced at least one drug error or "near miss". Although most errors (1,038) were of minor consequence (98%), four deaths were reported. The commonest error involved the administration of muscle relaxants instead of a reversal agent. "Syringe swaps" (70.4%) and the misidentification of the label (46.8%) were common contributing factors. Anesthesiologists (97.9%) reported that they read the ampoule label "most of the time" although the label colour was an important secondary cue. Approximately half of the participants would report the error if a reporting program existed and 84% agreed that improved standards for drug labels would reduce the incidence of error. Conclusions: Most anesthesiologists experienced at least one drug error. The commonest error was a "syringe swap" that involved a muscle relaxant. Most errors were of minor consequence, however, serious morbidity and mortality resulted from clearly preventable events. These results support the development of improved standards for drug labels and the establishment of a Canadian reporting program for medication errors. Objectif : 1) Découvrir si les anesthésiologistes ont vécu l'expérience d'une erreur de médication et 2) en déterminer les facteurs de causalité. Aussi, on a étudié la valeur perçue d'une agence de notification canadienne des erreurs de médication et de normes strictes des étiquettes d'ampoules de médicaments. Méthode : Une enquête d'autodéclaration a été postée aux membres de la Société canadienne des anesthési-ologistes (n = 2,266). Les répondants ont fourni des descriptions en textes libres des erreurs de médication et ont répondu aux questions à réponses fixes. Résultats : Les réponses reçues de 687 anesthésiologistes (taux de réponse de 30 %) ont révélé que 85 % des participants avaient fait au moins une erreur de médicament ou l'avait évitée de justesse. Même si la plupart des erreurs (1,038) n'ont eu que des conséquences mineures (98 %), quatre décès ont été rapportés. L'erreur la plus fréquente concernait l'administration de myorelaxants à la place de décurarisants. "L'échange de seringue" (70,4 %) et la mauvaise identification de l'étiquette (46,8 %) étaient souvent des causes d'erreur. Certains (97,9 %) ont dit lire l'étiquette sur l'ampoule "la plupart du temps" même si la couleur de l'étiquette était un important signal sec-ondaire. La moitié des participants environ auraient mentionné l'erreur si...

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Section: Medication Errors In Anesthetic Practice: a Survey Of 687 Prmentioning

confidence: 99%

Medication errors in anesthetic practice: a survey of 687 practitioners

Orser

Chen

Yee

2001

Can J Anesth/J Can Anesth

169

143

View full text Add to dashboard Cite

show abstract

“…In literature, there are several reports of various substances infused through epidural catheter inadvertently (2)(3)(4)(5)(6)(7)(8)(9)(10). However, there have been no reports describing inadvertent administration of dopamine through epidural catheter as in the case we present here.…”

Section: Introductionmentioning

confidence: 72%

Supraventricular Tachycardia Due to Dopamine Infused Through Epidural Catheter Accidentally (A Case Report and Review)

Coşkun¹,

Mahlı²

2012

Medicinal Chemistry and Drug Design

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“…Cases of erroneous epi-or peridural administration of potassium chloride have been reported (13,14). In our case number 7, a 55-year-old woman received 35 mL potassium chloride 7.5% peridurally instead of intravenously.…”

Section: Iatrogenic Intravenous Medication Errors 171mentioning

confidence: 78%