Holy S Hit I Just Gave The Wrong Medicine!!!

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jetproppilot

jetproppilot

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I've been in this business for twelve years now.

About halfway thru those twelve years, I gave a medicine I didnt intend to give.

Maybe you're thinking, Geez Jet, once in twelve years? Thats pretty good!

Or maybe you're saying Geez Jet, you're a *******!!!

The latter is right.

So I'm in this knee scope case and the pressures kinda high....healthy young patient....slow surgeon......tourniquets-getten'-to-her..so I'll slide in a little labetolol since the diastolic is increasing where I don't want it, and I don't wanna blast her with more anesthesia since I wanna discharge her 30 minutes after she hits the recovery room...

I grab the "labetolol" bottle, take out 2mLs (10mg) and squirt it in.

I set the bottle of "labetolol" on the table.

Pressure doesnt budge so 10 minutes later I grab the "labetolol".

This time I look closer at the bottle...

WTF????

A surge of electricity surges through my body in a bad way.

OH MY FU KKING GOD I JUST GAVE THIS GIRL.....

Antilirium?

To be honest, at the time, I didnt know what it was.

I'd never used it.

So I read the generic name...in little letters...

physostigmine.

I figure out I just gave this lady a parasympathomimetic....."Antilirium"....

happens to be a cuppla drug books on the pyxis....I look it up...

and figure out I just got really lucky.

Then I compare the labetolol bottle to the Antilirium bottle and they're pretty similar....

WE GIVE MEDICINES SO FREQUENTLY IN THIS BIZ, LADIES AND GENTLEMEN, IT'D BE VERY EASY TO KNOCK SOMEONE OFF WITH A MISTAKE.

I CAN'T EXPRESS TO YOU HOW IMPORTANT IT IS TO ESTABLISH SOME ROUTINE EARLY IN YOUR TRAINING.....

and stick to it.

Tell yourself I WILL NOT ADMINISTER A MED I DRAW UP UNLESS I LOOK AT THE BOTTLE/VIAL.

I don't know if human error can be eliminated.

My career is tarnished with a drug mistake....albeit a harmless one.

That mistake reinstilled in me how easy it is to make a drug error.

STRIVE TO KEEP YOUR CAREER UNTARNISHED.
 
Last edited:
Excellent advice. Any words of wisdom from the vets to new attendings like myself who are now supervising and often giving medications we didn't personally draw up?
 
BISof60 said:
Excellent advice. Any words of wisdom from the vets to new attendings like myself who are now supervising and often giving medications we didn't personally draw up?
Click to expand...

I'm in a primarily supervisory role.

Its a leap of faith.

You've gotta trust your employees.
 
I think this happens to just about everyone at some point. I think it stems from bottles looking the same. We had someone get a whole 1 mg of epi because the multidose epi vial looks like our decadron. other bottles that look the same that I have noticed are glyco and phenylephrine and hydralazine and vasopressin. There a bunch of others and it is not hard to see how it can and does happen. I think the take home point is actually read the vial. Even in a place you have been working at for a while, you never know when the pharmacy is going to get a better deal and switch vials on you. Look at the vials and label your syringes it sounds basic but sometimes when things get hectic the basics go out the window.

pd4
 
Mistakes happen - once in twelve years IS pretty good. Just curious, did you chart it on your anesthesia record? Also, you're right that it'd be easy to knock someone off with a mistake - but on the other hand, young healthy person; i'm always amazed at how resilient the human body is - it actually takes a lot to kill someone.
 
At my place both the phenylephrine vial and the reglan vial look really similar!

It's not happened yet, but it's one of my fears that phenyl would be given instead of reglan....I think this is why I try to look at every bottle 3 times.

Also, like someone said here...I think it's important to give meds that only YOU have drawn up.

I'm not saying this to be 'off the wall' or anything...however, a few months ago I read something in Anesthesiology News. If 'terrorists' or regular people that have gone rogue draw up stuff and leave them behind in syringes that are benign meds...ie epi in ephedrine labeled syringes....the consequences could be dire.

Call it paranoia..but I think the safest thing to do is draw up your OWN meds .....especially your rescue meds (pressors). You never know what's in that syringe by looking at it...unless it's propofol. Even that..who knows what someone else could have put in it.

When I had this weekend job working in a pharmacy back in college someone once told me. Pretend every time you are dispensing or giving a medication imagine as though you are giving it to your mother/father. That will definitely keep you on your toes....lol provided you like your mother/father .

Good thread Jet.
 
Dude your career is not tarnished.

This is an important lesson and everyone will have a drug error in their career, if they haven't already. Sometimes we work so quickly and are under so much stress or maybe we just don't pay enough attention - regardless everytime I draw up a med I make a clear and conscientious effort to check the label and silently repeat it to myself and to have it imprinted in my brain if only for a moment. It's way too easy to just grab a bottle from its usual place in the cassette and draw it up w/out really paying attention. You may be right 10,000 times in a row but eventually a mistake will get you.
 
SleepIsGood said:
At my place both the phenylephrine vial and the reglan vial look really similar!....
Click to expand...

Same thing at our institution. A couple of months ago I was about to prepare a bag of phenylephrine. Just before I drew it up, I looked at the bottle and it turned out to be Reglan. Our anesthesia techs had misstocked it.

Another similar example was a couple of weeks ago. I went to pull out a vial of nitroglycerin to show to a medical student. It turned out to be neostigmine instead. There were several misstocked bottles like this.

My medication error I recall was during a middle of the night C/S. I went to add 10 units of pitocin to the IVF (before we got the premixed bags), and instead pushed it IV by mistake. Luckily nothing bad happened.

Mistakes happen. All you can do is strive to be as careful as possible.
 
While I was training, there were two situations of an attending giving a drug a resident drew up and vice versa which was a medication error. Interestingly, they were both phenylephrine given instead of glycopyrolate at the end of the case with the neostigmine. By my third year, the pharmacy had changed the phenylephrine bottles because these two mistakes happened in the course of a year and a half. Both patients did OK, despite getting a 50 mg bolus of phenylephrine. One was even an old guy with heart problems! But it just jolts you in how easy it is to make a mistake and how much damage it could do.
 
As a resident, I was trying to get a patient's bp down for aortic cannulation before cpb.

I kept dialing the nipride up, but the bp kept going up. CT surgeon patiently waited...and waited...and waited...before I realized that I was dialing up the levophed😱

180/90 before I figured it out.
 
We just had a lecture on drug errors and the presenter offered that epi is probably the most dangerous drug in the cart, due to the cardiomyopathy it can cause. He emphasized the importance of system-level solutions; where I am, the only epi in the cart (everywhere other than heart rooms) is the boxed code stuff, so it looks REALLY different . . .
 
Ah, tunnel vision. Seeing what you expect to see and not what's really there.

The one drug swap I've made so far was at the end of a case when the patient was slow to wake up. Early in my CA-1 year ... everyone standing there looking at me, waiting for me to wake up the patient. Even the med student who'd just taken 20 minutes to close with his seven thumbs was glaring at me. My attending thought I'd over narc'd the patient so he tells me to break out the Syringe of Shame and give some Narcan. Embarrassing.

So I open the cart and reach for the naloxone ampule. I don't immediately see it, but there in its spot is a vial. I remember thinking (illogically) that Hmm, we must have a new supplier for Narcan and now it comes in vials. I read the label. Drew it up, diluted it to 10 mL, and read the label again. Put a sticker on the syringe and wrote "Narcan .04/mL" on it. Started giving 1 cc at a time. After about 10 minutes and a few hits, the patient woke up and we went to PACU. Attending goes "See, you gave him too much fentanyl."

I was setting up for the next case when I realized the vial was flumazenil. Shocked the hell out of me because I was convinced I was giving naloxone.
 
Mapleson D said:
We just had a lecture on drug errors and the presenter offered that epi is probably the most dangerous drug in the cart, due to the cardiomyopathy it can cause. He emphasized the importance of system-level solutions; where I am, the only epi in the cart (everywhere other than heart rooms) is the boxed code stuff, so it looks REALLY different . . .
Click to expand...

I hate Gabba and his system based shi t.

I gave the wrong drug....It's my fault...no one elses..not the system...not the surgeon.

I hate it when WE (doctors) want to blame "systems" and not ourselves, when we screw up.
 
Mapleson D said:
We just had a lecture on drug errors and the presenter offered that epi is probably the most dangerous drug in the cart, due to the cardiomyopathy it can cause. He emphasized the importance of system-level solutions; where I am, the only epi in the cart (everywhere other than heart rooms) is the boxed code stuff, so it looks REALLY different . . .
Click to expand...

more so than a 10 mg shot of phenylephrine?
 
rsgillmd said:
Same thing at our institution. A couple of months ago I was about to prepare a bag of phenylephrine. Just before I drew it up, I looked at the bottle and it turned out to be Reglan. Our anesthesia techs had misstocked it.

Another similar example was a couple of weeks ago. I went to pull out a vial of nitroglycerin to show to a medical student. It turned out to be neostigmine instead. There were several misstocked bottles like this.

My medication error I recall was during a middle of the night C/S. I went to add 10 units of pitocin to the IVF (before we got the premixed bags), and instead pushed it IV by mistake. Luckily nothing bad happened.

Mistakes happen. All you can do is strive to be as careful as possible.
Click to expand...


Hey dude...can you tell us what the ppl did that gave the phenylephrine by accident. I'm thinking when you give 10mg of phenyl IV the pressure is going to go from 90/60 to 200/110 ...is it that dramatic? What was the management if you recall? Did they give NTG? Increased the volatile? Anyone can chime in...I'm curious...
 
SleepIsGood said:
Hey dude...can you tell us what the ppl did that gave the phenylephrine by accident. I'm thinking when you give 10mg of phenyl IV the pressure is going to go from 90/60 to 200/110 ...is it that dramatic? What was the management if you recall? Did they give NTG? Increased the volatile? Anyone can chime in...I'm curious...
Click to expand...

One of my fellow residents, in his first week as a CA-1, drew up a syringe of phenylephrine. He didn't know our standard prep for emergency drugs was a 100 mcg/mL dilution so he did a single dilution - put 10 mg in a 10 mL syringe and diluted it with saline to make 1 mg/mL. He labeled it properly, ie "phenylephrine 1 mg/mL".

In the midst of a case his attending grabbed the syringe, pushed a couple mLs without looking at the label, and the pressure went up into the mid-200s. What happened next is a matter of hearsay, but I was told the attending called for help, and somebody else came in, looked at the pressure, drew up some NTG, and gave it. (Odd that she didn't do these things herself.) The patient was fine, but they made the resident do an M&M for it and abused him doubly because he had the audacity to point out that (a) he'd never been told how to draw it up, (b) he labeled the syringe properly, and (c) someone else took the drug and pushed it without reading the label.

Moral of the story - at M&M, always take the blame even if someone else blew it. 🙂
 
As a CA-1 maybe my 2nd month - I was in a room by myself (after working with a classmate for the first 6 weeks) in an AV graft for the first time under a supraclavicular block that was working just fine. Surgeon asks me to give 4,000 units of heparin - first time ever administrating Heparin - I search the drug drawer find the vial and quickly read the large number "1000 units" but did not read "1000 units/ml" - they were 10 ml vials and somehow I assumed it was 100 units/ml - I remember saying to the circulating nurse that I needed 2 more vials (as I only had 2 vials in the drawer) - and told the surgeon as well - no one questioned me - and I pushed the 4 vials.

I didn't realize my mistake until the next case (same surgeon, same type of surgery) when the surgeon asked me to give 5,000 units of heparin this time - and that's when I looked at the vial more closely again and realized I just given the previous patient 40,000 units of heparin!!! 😱

I obviously freaked out - called my attending quietly and asked him to come to the room - if I told the surgeon he would have my head - after picking up my attendings eyeballs from the floor - he ran to the PACU only to find out the patient had been discharged already!! it had been over an hour and half - we called him at home and told him about the drug error and if any bleeding occurred to come back to the hospital a.s.a.p.

Since that day 4 years ago - I always look at the vial of every drug I draw up and kind of murmur to myself the drug and the concentration as I draw it up and label it - especially syringes for regional blocks where i mix two different LA's in a syringe.
 
militarymd said:
As a resident, I was trying to get a patient's bp down for aortic cannulation before cpb.

I kept dialing the nipride up, but the bp kept going up. CT surgeon patiently waited...and waited...and waited...before I realized that I was dialing up the levophed😱

180/90 before I figured it out.
Click to expand...


why would you have levophed hanging anyway prior to cannulation, usually its the downers we have hangin.. if we need an upper we gi ve a squeeze of something. post pump another story but my doc there is epi
 
maceo said:
why would you have levophed hanging anyway prior to cannulation, usually its the downers we have hangin.. if we need an upper we gi ve a squeeze of something. post pump another story but my doc there is epi
Click to expand...

You don't do too many hearts, right?
 
it is terrifying how often situations like those mentioned in this thread can happen. availability of items (and contracts) change all the time, and manufacturers even do the old bait and switch and change labelling....

was signing a bag of amio for a coding patient today....my tech handed me a clear vial? i'm thinking, "uh oh"......nope, different brand than the amber vials i have seen and used a million times. i handle DRUGS all day and really see how easy it is to make a mistake. we were taught "RL3"....read the label three times. it helps!

be careful up in your OR's, guys....we don't mis-stock things on purpose (but pharmacy makes mistakes, too)....and i can't agree more with drawing up your own stuff!
 
When I was a CA3 resident I had a CA1 who used 5 vilas of Phenylephrine (50mg) instead of 5 vials of Robinul to mix with Neostigmine for reversal at the end of the case.
The patient was a young healthy patient for appendectomy.
The last BP before cardiac arrest was something like 260/150, he ultimately left the hospital in good shape.
 
Closest I've yet come to a goof was picking up the "Neostigmine" out of the drawer at the end of case, drawing it up, and almost giving it, until I did a double-take and realized someone had put Etomidate in the Neostigmine slot - same size vial, same color top. Yup, that woulda been a pretty slow reversal... Can you imagine, top it off with some Glyco, and god only knows how high his pressure might have gone...
 
militarymd said:
I hate Gabba and his system based shi t.

I gave the wrong drug....It's my fault...no one elses..not the system...not the surgeon.

I hate it when WE (doctors) want to blame "systems" and not ourselves, when we screw up.
Click to expand...



As someone with some exposure to human factors engineering, I'd have to majorly disagree.

Some of the biggest strides in our profession have been made in terms of changing systems to result in better patient safety.

People make mistakes. Always have, always will. I don't care how vigilant you are, you will screw up. The goal is to design systems that are more difficult to screw up in.

A mistake nearly always has human error as part of it. So the person that made the mistake is of course partly to blame (how much depends on the situation). But from a systems point of view, the goal is to help ensure that a similar mistake isn't made by somebody else in the future. Blaming the individual and saying "do it better next time" doesn't really help. Trying to make the system more idiot proof does help.


I always blame myself when I screw up. I'm human, it happens. But it is worthwhile to see if there are design flaws in the systems that we use that facilitate errors and don't do enough to prevent them.
 
Mman said:
As someone with some exposure to human factors engineering, I'd have to majorly disagree.

Some of the biggest strides in our profession have been made in terms of changing systems to result in better patient safety.

People make mistakes. Always have, always will. I don't care how vigilant you are, you will screw up. The goal is to design systems that are more difficult to screw up in.

A mistake nearly always has human error as part of it. So the person that made the mistake is of course partly to blame (how much depends on the situation). But from a systems point of view, the goal is to help ensure that a similar mistake isn't made by somebody else in the future. Blaming the individual and saying "do it better next time" doesn't really help. Trying to make the system more idiot proof does help.


I always blame myself when I screw up. I'm human, it happens. But it is worthwhile to see if there are design flaws in the systems that we use that facilitate errors and don't do enough to prevent them.
Click to expand...

I believe Atul Gawande included a bit of this in his book "Complications". He discussed how an anesthesiologist and an engineer had taken deaths due to anesthesia complications from one or two in every 10,000 operations in 1960 to one in 200,000 cases just a decade later. This was accomplished by standardizing the anesthesia machines and improving the monitoring... I agree with needing to take blame, and it seems like we have become quick to blame any and all others instead of ourselves. At the same time it does help to have safeguards in place.

That being said, I'm not familiar with the system that you are talking about and sometimes it seems like it can be taken to an extreme... so that might be a case that you are talking about.

-RT2MD
 
Engineering a better system is fine with me.

My issue is not with engineering a better system.

My issue with gabba's attitude...and those who subscribe to his attitude.

The attitude of : blame the system NOT the individual.

I advocate blaming the individual....if you have someone motivated enough and well trained enough...you can do anesthesia safely on a rocking ship in the middle of a turbulent sea while a war is going around you with the power going on and off intermittently.

I'm OK with blaming the individual and working on improving the system.

I'm NOT ok with blaming the system and not the individual ...which is what I hear Gabba say when I listened to him talk and ASKED him what he believes.

Because if that's the case....lets just engineer a system where a monkey can do our job.


Mman said:
As someone with some exposure to human factors engineering, I'd have to majorly disagree.

Some of the biggest strides in our profession have been made in terms of changing systems to result in better patient safety.

People make mistakes. Always have, always will. I don't care how vigilant you are, you will screw up. The goal is to design systems that are more difficult to screw up in.

A mistake nearly always has human error as part of it. So the person that made the mistake is of course partly to blame (how much depends on the situation). But from a systems point of view, the goal is to help ensure that a similar mistake isn't made by somebody else in the future. Blaming the individual and saying "do it better next time" doesn't really help. Trying to make the system more idiot proof does help.


I always blame myself when I screw up. I'm human, it happens. But it is worthwhile to see if there are design flaws in the systems that we use that facilitate errors and don't do enough to prevent them.
Click to expand...
 
militarymd said:
Engineering a better system is fine with me.

My issue is not with engineering a better system.

My issue with gabba's attitude...and those who subscribe to his attitude.

The attitude of : blame the system NOT the individual.

I advocate blaming the individual....if you have someone motivated enough and well trained enough...you can do anesthesia safely on a rocking ship in the middle of a turbulent sea while a war is going around you with the power going on and off intermittently.

I'm OK with blaming the individual and working on improving the system.

I'm NOT ok with blaming the system and not the individual ...which is what I hear Gabba say when I listened to him talk and ASKED him what he believes.

Because if that's the case....lets just engineer a system where a monkey can do our job.
Click to expand...

Not all mistakes are created equal. In the case of drawing up drugs, a trained monkey CAN do our jobs just as well as we can. I can take the Janitor and w/5 minutes train him/her to draw up syringes just as well as a seasoned anesthesiologist. The skills aren't tough to teach, how to check you're work isn't tough to teach. It truley is a monkey skill.

It is these kinds of mistakes where a system needs to be put into place to help prevent errors b/c WE ARE ALL HUMAN, and human being make careless mistakes. Nothing we can do about b/c given enough time we will all screw up. Creating a system that makes it tough to screw up is the solution b/c WE ARE ALL HUMAN and will all make a mistake.

Other mistakes such as giving neo when we should give ephedrine based on the pts vitals are the types of mistakes where we should place the blame on the individual and not the system b/c it is the individual who is trained to make the right choice.
 
yeah.....right.

me454555 said:
Not all mistakes are created equal. In the case of drawing up drugs, a trained monkey CAN do our jobs just as well as we can. I can take the Janitor and w/5 minutes train him/her to draw up syringes just as well as a seasoned anesthesiologist. The skills aren't tough to teach, how to check you're work isn't tough to teach. It truley is a monkey skill.

It is these kinds of mistakes where a system needs to be put into place to help prevent errors b/c WE ARE ALL HUMAN, and human being make careless mistakes. Nothing we can do about b/c given enough time we will all screw up. Creating a system that makes it tough to screw up is the solution b/c WE ARE ALL HUMAN and will all make a mistake.

Other mistakes such as giving neo when we should give ephedrine based on the pts vitals are the types of mistakes where we should place the blame on the individual and not the system b/c it is the individual who is trained to make the right choice.
Click to expand...
 
i had an alaris infusion pump that had not been programmed but was connected to a unit that was on, with no other infusions running, malfunction and deliver about 8mg of levophed. We had just canulated and were priming the pump when the pressure went skyhigh (i had just moved the norepi to another channel) and we had to go on pump and give nipride in the pump to keep MAP < 100. I hung insulin about 20 minutes later and noticed that the drip chamber from the levophed bag was running (pretty quickly) and the bag was almost empty. Checked the line and everything was as it should be, except the channel, which wasnt programmed to deliver anything, was just pumping in the norepi. Lady did fine.
 
One of my attendings told a similar story that happened to him during training. The short version is the pt, who happened to be a surgeon there, was getting a knee scope & asked to be more sedated. The attending was 1-on-1 with a new CA-1 and team was also trying to get the pro-op abx in as well as improve the sedation. A 'drug' was given & within a few seconds the pt/surgeon began complaining of increasing SOB & looking mighty da mned scared. The staff person realized $hit was not kosher when he noted the shallow resps and quickly induced & intubated the guy. After digging through the sharps bin, it was discovered the abx was actually Sux!

That has really stuck in my head! Every time I draw up a med, I make sure htat I do it & that I am directly visualizing the label as a I draw it. It ain't perfect & I am far far from perfect, but I believe in doing everything I can do to minimize screw-ups. The way I figure it, in our gig, one small boo-boo on our part & you can quickly end up with a very hurt, dead or even worse pt outcome. And for me, no amount of financial ruin would compare with the anguish & burden I would carry inside of me forever.
 
Mapleson D said:
We just had a lecture on drug errors and the presenter offered that epi is probably the most dangerous drug in the cart, due to the cardiomyopathy it can cause.
Click to expand...

I'm not sure about this. I can't tell you how many times I have heard of someone giving epi in a patient instead of the intended drug (I did it myself when rotating at another institution and their epi vials looked liked our neosynephrine vials - luckily it was double diluted) and I don't remember hearing once that patient had a problematic outcome.

Parenthetically if board takers are reading - the right answer to accidental overdose of epi is NEVER giving a beta blocker.
 
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