Case reports received by CHPSO provided the lessons learned for
this issue. Following are brief examples. Details may have been
changed to protect patient and provider confidentiality.
BCMA: An ICU patient was on several vasopressor
infusions: epinephrine and norepinephrine. The nurse noted that
the epinephrine infusion was nearly empty, walked over to the
Automated Dispensing Cabinet (ADC) and obtained another bag. The
medication scanned properly and was hung to replace the
epinephrine. Minutes later, increasing blood pressure alerted the
nurse, and he then noted that two norepinephrine infusions were
now running instead of one. He thought he had requested
epinephrine from the ADC, but the records show he made a mistake
when recalling which medication was needed, and requested and
obtained norepinephrine instead.
Multi-dose Vials: In the operating room, an
anesthesiologist started inducing the patient for anesthesia.
Initially, she injected a sedative from a syringe; then the
patient developed respiratory distress and anxiety. Recognizing
that she had accidentally injected the muscle relaxant instead of
the sedative, the anesthesiologist rapidly proceeded with a
bolus of intravenous anesthetic and intubated the patient.
Investigation of the incident found several issues.
Anesthesiologists were required to draw up their own medications:
to save time, this anesthesiologist was not labeling all her
syringes, expecting to differentiate between them based on
syringe size. Also to save time, she was preparing the syringes
for the next case as the prior case was finishing, using
multi-dose vials in the operating room for some of the
medications, even though multi-dose vials can only be used for a
single patient when the vial is in the operating room.