Malpractice case

[undalay]

I heard of this case in California. Remember when some of the spinals That we performed would not work, many of us would draw the 0.75% spinal bupivacaine from outside the spinal pack. Some ***** from pharmacy stocked the digoxin vials where they were supposed to stock bupivacaine, a look Alike vial. The inattentive nurse breaks open the vial and now the anesthesiologist draws it up and administers the spinal. And then the lawyers take over.

State fines Mercy Hospital Southwest after anesthesiologist errs and injects woman in labor with 'toxic' medication

An anesthesiologist at Mercy Hospital Southwest who stated he was "in a hurry" accidentally injected heart failure medication, rather than the numbing medication he intended, into the back of a

www.bakersfield.com

The reason I bring this case here is that the malpractice company told the group that they cannot be insured. There must be more to the story. Then a national AMC takes over.

No matter at the end it is the fault of anesthesiologist. I think one should not hurry up aneshesia. We should be given adequate time for anesthesia and not let be pushed over by obstetrician, nurses, hospitals administrators.

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[patriot6]

I heard of this case in California. Remember when some of the spinals That we performed would not work, many of us would draw the 0.75% spinal bupivacaine from outside the spinal pack. Some ***** from pharmacy stocked the digoxin vials where they were supposed to stock bupivacaine, a look Alike vial. The inattentive nurse breaks open the vial and now the anesthesiologist draws it up and administers the spinal. And then the lawyers take over.

State fines Mercy Hospital Southwest after anesthesiologist errs and injects woman in labor with 'toxic' medication

An anesthesiologist at Mercy Hospital Southwest who stated he was "in a hurry" accidentally injected heart failure medication, rather than the numbing medication he intended, into the back of a

www.bakersfield.com

The reason I bring this case here is that the malpractice company told the group that they cannot be insured. There must be more to the story. Then a national AMC takes over.

No matter at the end it is the fault of anesthesiologist. I think one should not hurry up aneshesia. We should be given adequate time for anesthesia and not let be pushed over by obstetrician, nurses, hospitals administrators.

The nature of the work will always be hurried.
It's up to the individual to slow down and stop if necessary.
I'm still pretty green, but I don't allow others to rush me.
It takes significant effort.

 

[repititionition]

I saw firsthand a similar case (too many cooks in the kitchen) where a patient received intrathecal TXA. Agree you have to know when and how to "stop the line".

 

[Planktonmd]

So, let's play devil's advocates: Digoxin works on sodium channels just like local anesthetics, so I bet she had a great spinal
The seizure activity and hypertension might be simply because she was eclamptic?
Someone needs to study the use of digoxin in spinal anesthesia.

 

[coffeebythelake]

So, let's play devil's advocates: Digoxin works on sodium channels just like local anesthetics, so I bet she had a great spinal
The seizure activity and hypertension might be simply because she was eclamptic?
Someone needs to study the use of digoxin in spinal anesthesia.

Accidental Intrathecal Administration of Digoxin : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

Dose related? High spinal with digoxin? What is the baricity?

 

[undalay]

https://www.acmt.net/_Library/2017_ASM_Abstracts/ACMT2017_047.pdf

AANS | E-Poster Abstract

360.aans.org

 

[undalay]

Digiband , antibody and dexamethasone in high doses seems to help. It looks like there are more cases in literature. Seems like it was mistaken for lidocaine too in this patient

 

[deleted126335]

So, let's play devil's advocates: Digoxin works on sodium channels just like local anesthetics, so I bet she had a great spinal
The seizure activity and hypertension might be simply because she was eclamptic?
Someone needs to study the use of digoxin in spinal anesthesia.

In other words, The defense’s position is, “yes we breached the standard of care, but this is not what caused the Plaintiff’s injuries”. Uh-huh.

 

[deleted875186]

I have seen the digoxin ampule in one hosptial OR pixis before and was shocked how similar it was to the heavy bupi vial. The writing on those ampules is so tiny as well.

Why are hosptial ORs still putting digoxin in anesthesia pixis machines. I cannot think of a single time I would need digoxin urgently enough that I could not wait for this to be delivered by pharmacy.

 

[undalay]

This is a case of systematic problems with alignment of Swiss cheese model for safety incidents. There are not enough pharmacy technicians in most hospitals, most of the essential drugs are locked up . The Pyxis machines are from 1950s and they take their sweet time to give one drug at a time. And then they jerry rigged a bar code to that to slow it even more. in a short period of time you have to do more steps in less Time. The system is not going to invest huge money to deliver actual change. And the system is not punished for it.

The response after this is that every time the spinal is done one has to show the vial of bupivacaine to the nurse and get it confirmed before injection.

 

[coffeebythelake]

This is a case of systematic problems with alignment of Swiss cheese model for safety incidents. There are not enough pharmacy technicians in most hospitals, most of the essential drugs are locked up . The Pyxis machines are from 1950s and they take their sweet time to give one drug at a time. And then they jerry rigged a bar code to that to slow it even more. in a short period of time you have to do more steps in less Time. The system is not going to invest huge money to deliver actual change. And the system is not punished for it.

The response after this is that every time the spinal is done one has to show the vial of bupivacaine to the nurse and get it confirmed before injection.

absolutely agree. while it is crucially important to read the vial, no system should fail from a single point of error.

the fact that drug errors like this happen with regularity says a lot about the system that allowed it to happen. Digoxin should not be stocked anywhere near lidocaine or bupivicaine especially if they are in similar looking vials. we've seen it with phenylephrine vials being mistaken for ondansetron. we've seen it with superconcentrated doses of some drugs being mistaken for a lower concentration. drug manufacturers need to also take some responsibility for this.

 

[deleted875186]

This is a case of systematic problems with alignment of Swiss cheese model for safety incidents. There are not enough pharmacy technicians in most hospitals, most of the essential drugs are locked up . The Pyxis machines are from 1950s and they take their sweet time to give one drug at a time. And then they jerry rigged a bar code to that to slow it even more. in a short period of time you have to do more steps in less Time. The system is not going to invest huge money to deliver actual change. And the system is not punished for it.

The response after this is that every time the spinal is done one has to show the vial of bupivacaine to the nurse and get it confirmed before injection.

Not surprising, knee jerk reaction that does nothing to fix any of the route problems.

Meanwhile we have to demonstrate how we would do a quality improvement project at a hosptial tk be board certified in anesthesia …. What an absolute joke.

 

[ethilo]

We had equivalent-appearing vials of 0.5% bupi and mineral oil in slots next to each other in the core pyxis of our OR. I put a quick stop to that one.

Just imagine injecting mineral oil intrathecally....

 

[undalay]

absolutely agree. while it is crucially important to read the vial, no system should fail from a single point of error.

the fact that drug errors like this happen with regularity says a lot about the system that allowed it to happen. Digoxin should not be stocked anywhere near lidocaine or bupivicaine especially if they are in similar looking vials. we've seen it with phenylephrine vials being mistaken for ondansetron. we've seen it with superconcentrated doses of some drugs being mistaken for a lower concentration. drug manufacturers need to also take some responsibility for this.

The drugs/devices are being manufactured in Bulk in another continent. Then being packaged in another. Finally when they arrive here and we use it no one knows how many supply chains have maintained the temp that they were supposed to be at. Finally we happen to be the end users. I document the lot number and also the expiry date of every drug,

There is a lot of distraction in the OR, the Radio or the music is on loudly, and the Ortho rooms the techs are teaching the traveling techs every step and to get any bodies attention you have to yell.

Pharmacy does not even stock enough muscle relaxants for all the cases. Luckily they have phenylephrine 100 mcg 10 ml syringes. But ephedrine they lock up. Vasopressin is in the Pyxis in the core and there is only one nurse in the or.

 

[caligas]

One piece of advice I give trainees is to really program yourself to read labels every time, including ones that “can only possibly be the drug you expect” such as the bupiv in a kit, the zofran in the little zofran cubby of your drug tray etc.

 

[MirrorTodd]

One piece of advice I give trainees is to really program yourself to read labels every time, including ones that “can only possibly be the drug you expect” such as the bupiv in a kit, the zofran in the little zofran cubby of your drug tray etc.

Agreed, I was taught during my medic training for the Army that there are 5 variables that need to be correct before administering any drug: right patient, right time, right route, right dose and right drug.

Long and short of it all is that the buck stops with you if you are the one pushing the drug and that should be passed over to the future as well. Anyone who pushes the wrong drug or dose or whatever has no one to blame but themselves.

 

[ISoNitrous]

When I think of a “clean kill,” I think of administering the wrong medication intrathecally. Muscle relaxants, TXA….

You give the wrong medication IV? Oftentimes some sort of reversal agent or drug that does the opposite thing that can be administered.

But a wrong medication given through a spinal needle, and the die has been cast. Unless you are going to CSF lavage!

While I will give a CRNA the benefit of the doubt that the rocuronium-labeled syringe actually has Roc in it, anytime I’m giving spinal medication, I am the one double checking the label as the nurse draws it or as I draw it myself.