do you read every label?
Started by caligas
try to. Definitely a bad habit to not do it, but so easy to not do it. I've seen/heard too many stories of people giving the wrong drug with a look alike vial.
Yes -- a resident colleague once reparalyzed a patient when he thought he was giving reversal. He figured it out when the patient didn't resume breathing. I've learned from his mistake.
My hospital likes to order the same drug in different colored vials, so I have to pay attention. Our ASC has different colors too
I admit that I do not read the propofol label, but I do read everything else for the reason that Oggg mentioned. I think we have 4 different styles of 10 mL vials for sterile saline alone.
same here. among my favorite lookalikes between our place and our affiliates:
-calcium chloride and neostigmine
-zofran style #1 and hydralazine
-zofran style #2 and methergine
-lidocaine, atropine, and dilaudid
At one of our hospitals the phenylephrine 10 mg 1ml vials and glycopyrrolate 0.2 mg 1 ml vials not only look identical, they are in nearly the same location on our drug tray. Furthermore, on more than one occasion I have noted phenylephrine in the glyco spot after the techs have restocked the trays. Just asking for an incredibly disastrous drug error.
If the pharmacy can't change the supplier, you can move it in the tray to the opposite side, etc. Consider changing to pre filled syringes as well if they can't get get a different vial.
That error will be an assassination.
That error will be an assassination.
Incidentally, I've spoken with 2 individuals (a doc and a CRNA) that both gave 10mg phenylephrine thinking it was something else. Both patients lived without any sequelae. Crazy, but thank God patients can tolerate more than we sometimes think they can. I think I remember both saying peak SBP was only like 250. Crazy!!!
We had a couple M&Ms for a phenylephrine errors / drug swap when I was a resident. Someone gave 10 mg of it instead of 4 mg Zofran. Patient did fine. Someone else (a brand new CA1) didn't double-dilute the 10 mg/mL --> 100 mcg/mL because he was new, even correctly labeled the syringe 1 mg/mL, and his attending picked it up and gave the drug without reading the label. That patient also did fine.
I did drug swap once, think I was a CA1. Wanted to give some Narcan, but pulled the flumazenil vial out instead. Read the label. I even remember thinking "hmm, they must've changed forumulations, the vial is different" ... looked at the label, drew it up. Put a label on the syringe and wrote Narcan on it. For some reason I just saw what I expected to see and my brain didn't click. It was a weird experience, I still can't explain it.
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You get 250 SBP when you exercise easily...
Kind of funny this thread comes up, especially with Propofol by the OP.
Doing a rotation here in Sicily and they have both 1% and 2% Propofol. Mainly use Propofol 1% for induction and use the 2% for running TIVA while on pump (They can't run inhalational agents during bypass).
Yes. I read each label every time. No exceptions. No excuse to deviate from this safety practice.
One of the hospitals I work at has now switched from the epinephrine with the orange label and the break away top to a vial with a flip top labeled "adrenalin," which looks identical to zofran and is in the next slot.
I have had 2 close calls, but thankfully caught my mistake. I've thrown a few hissy fits at the pharmacists that stock our omnicells, but they haven't changed it.
I have had 2 close calls, but thankfully caught my mistake. I've thrown a few hissy fits at the pharmacists that stock our omnicells, but they haven't changed it.
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