Drug swap

[nimbus]

https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf

State fines Mercy Hospital Southwest after anesthesiologist errs and injects woman in labor with 'toxic' medication | News | bakersfield.com

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[kidthor]

That is awful for the patient and also for the anesthesiologist. I've certainly made errors myself (and everyone has) - this one was quite, quite unlucky.

 

[narcotics999]

So the second dose was digoxin. The pt still had c/s. Meaning the first bupi did work but took a while???

Awful.

 

[coffeebythelake]

How the F did digoxin get confused with bupivicaine. I triple check the bupivicaine just to make sure it is the right concentration.

 

[vector2]

How the F did digoxin get confused with bupivicaine. I triple check the bupivicaine just to make sure it is the right concentration.

This exact mixup happened in my neck of the woods to a resident a couple years back. Pyxis had dig right next to bupi and apparently the vials look really similar. Pt seized and apparently suffered some degree of paralysis as well.

 

[coffeebythelake]

This exact mixup happened in my neck of the woods to a resident a couple years back. Pyxis had dig right next to bupi and apparently the vials look really similar. Pt seized and apparently suffered some degree of paralysis as well.

This is why we always need to check and read thr labels.

 

[deleted59964]

Terrible for all concerned.
Humans make errors, the public will never understand that an otherwise competent doctor can do things like this ... but we know different.

We have to try to prevent these errors by looking at the root cause. Sure - the anaesthesiologist should have checked the ampoule but I really think it would reduce drug class errors is to legislate that the packaging for a class of drugs has a characteristic appearance.

eg
Pressors - purple line
Local Anesthetics - Yellow line
NMB - Red line
Opioids - Blue Line

etc. etc.

 

[IlDestriero]

How the F did digoxin get confused with bupivicaine. I triple check the bupivicaine just to make sure it is the right concentration.

I’m with you! The constant changing of the drug suppliers and what the ampules/vials look like makes me paranoid 24/7 about drug swaps, when I’m drawing up drugs I triple check and if someone is talking to me, I ask them to wait.
Sad but avoidable error.

 

[IMGASMD]

I have almost done the same thing. Thankfully I caught it. Certainly makes me paranoid every time I am up in l&d.

It’s the constant changing of suppliers, different kit to “contain cost” or back order of essential drugs in the kit that makes a routine block more difficult than it should be.

I can certainly sympathize with the anesthesiologist, with a screaming patient and screaming surgeon..... if the vial looks the same or maybe someone handed me the drug (since I am sterile) I’d just do it.

 

[deleted875186]

I catch myself all the time not reading vials and grabbing them based on appearance.

While I do think there is a system problem with he way medications are packaged and where in the hospital and omnicell they are placed, we have to be paranoid when injecting things epidural, intrathecal, etc. stories like these make me slow down and read everything when doing spinal and epidurals.

I think one easy fix is to use spinal and epidural kits with medications included.

 

[Simba1711]

i have almost done the same thing as well. In hind sight I should of checked the labels but I can definitely see why other people would make a similar mistake At our hospital. The nitroglycerin syringe looks exactly the same as the precedex syringe. It is dangerous IMO. Same size syringe. They have a white label on them with the medication typed. Pharmacy then highlights the text with a purple highlighter for both.

Attending’s have mixed up phenylephrine and epi quite a few times bc the syringe looks exactly the same.

 

[Beeftenderloin]

At our place the 100cc TXA bags and 100cc insulin bags from pharmacy look identical except for the name which is buried in a sea of 10 point font text.

System wide we’ve had 3 incidents in the past 2 months where patients got 100u of insulin in stead of their TXA bolus. Supposedly pharmacy is working on a solution, but at the end of the day nothing beats vigilance.

 

[coffeebythelake]

At our place the 100cc TXA bags and 100cc insulin bags from pharmacy look identical except for the name which is buried in a sea of 10 point font text.

System wide we’ve had 3 incidents in the past 2 months where patients got 100u of insulin in stead of their TXA bolus. Supposedly pharmacy is working on a solution, but at the end of the day nothing beats vigilance.

An easy solution here is to put a big red label that says INSULIN.

 

[vector2]

An easy solution here is to put a big red label that says INSULIN.

Sounds good in theory, but let’s have 5 committee meetings to study the issue and make sure 16 clipboard nurses sign off before we implement it

 

[coffeebythelake]

Sounds good in theory, but let’s have 5 committee meetings to study the issue and make sure 16 clipboard nurses sign off before we implement it

You sure we dont work in the same hospital?

 

[Beeftenderloin]

An easy solution here is to put a big red label that says INSULIN.

Obviously this solution was floated to pharmacy. Pharmacy’s response (I wish I was joking) was that they didn’t want to be held responsible in the event that one of their techs either forgets to put the sticker on, or stickers the wrong bag.

 

[deleted875186]

Obviously this solution was floated to pharmacy. Pharmacy’s response (I wish I was joking) was that they didn’t want to be held responsible in the event that one of their techs either forgets to put the sticker on, or stickers the wrong bag.

Unbelievable.

Tell them to just put a big red high alert sticker on it then. There needs to be some marker on a medicine that can easily kill someone with a drug error.

 

[caligas]

Obviously this solution was floated to pharmacy. Pharmacy’s response (I wish I was joking) was that they didn’t want to be held responsible in the event that one of their techs either forgets to put the sticker on, or stickers the wrong bag.

Uh, their refusal to cooperate with a safety initiative is what will make them responsible

 

[kidthor]

Obviously this solution was floated to pharmacy. Pharmacy’s response (I wish I was joking) was that they didn’t want to be held responsible in the event that one of their techs either forgets to put the sticker on, or stickers the wrong bag.

Tell them to put that in writing and then you can whistleblow that to the government.

 

[Aether2000]

We really need writing that is not microprinted on the vials and ampules. Some of the print is so small that several of us needed a magnifying glass to identify the drug in a one ml ampule.
Yeah, I know age doesn't help, but when several people cannot read a label because the print is notably smaller than any other drug, there is a problem.

 

[urge]

Your spinal trays don't have bupivacaine inside?

 

[Aether2000]

Ours do not.

 

[Impromptu]

Bupivacaine containing spinal trays went away 1-2 years ago with the most recent spinal bupivacaine shortgage.

After learning more about high reliability tasks I have slowed some key tasks down. Slowing tasks down is the solution to many human errors, though nothing will ever eliminate errors completely. Double checking a task adds on negligible time to my day.

 

[deleted162650]

Bupivacaine containing spinal trays went away 1-2 years ago with the most recent spinal bupivacaine shortgage.

They transiently went away, but they're back now.

 

[narcotics999]

They transiently went away, but they're back now.

We had a batch of bupi in the kit not working. Very annoying. Pharmacy claimed bad transportation and storage conditions for the kits.

 

[Aether2000]

It is possible to order trays with or without bupivacaine, but I have yet to see digoxin as an option in spinal trays ;-)

 

[nimbus]

It is possible to order trays with or without bupivacaine, but I have yet to see digoxin as an option in spinal trays ;-)

The event occurred in summer 2018. At that time there was a shortage of heavy spinal bupivacaine and trays were coming without local. Probably altered the doctor’s usual routine and workflow. Really unfortunate.

 

[txhorn]

We had a batch of bupi in the kit not working. Very annoying. Pharmacy claimed bad transportation and storage conditions for the kits.

Had the same thing happen to me a couple of times in the past month.

 

[Twiggidy]

Sounds good in theory, but let’s have 5 committee meetings to study the issue and make sure 16 clipboard nurses sign off before we implement it

Write a note or email to someone important and include "Detrimental to patient safety", etc....now it's in writing. You'll hear back from someone QUICKLY.

 

[coffeebythelake]

I've resorted to do a lot of this myself. Whenel dealing with meds where drug errors would be very serious or potentially fatal, I put a big red X on the syringe or bag. E.g. insulin. I also do not draw up such drugs until I really need it.

 

[deleted697127]

Having digoxin out accessible as a routine drug or even on a labor floor for that matter seems a little odd. I’m curious how many people on this board have ever personally given it.

 

[Crabbygas]

20 plus years of doing anesthesia and I have never given dig. It should not have been in the OR much less an L and D OR.

 

[nimbus]

I've resorted to do a lot of this myself. Whenel dealing with meds where drug errors would be very serious or potentially fatal, I put a big red X on the syringe or bag. E.g. insulin. I also do not draw up such drugs until I really need it.

Same. I wrap plastic pink tape on the syringe as a reminder to myself.

 

[nimbus]

Digoxin was in most carts when I started. It was given for rate control in afib in the pre-dilt drip days. I gave it many times and it rarely worked.

 

[Aether2000]

It does make me wonder what exactly we were giving in the spinal fluid of patients in the summer of 2018 since it clearly was not bupivacaine. There was not even a hint of blockade in many patients.

 

[Twiggidy]

Having digoxin out accessible as a routine drug or even on a labor floor for that matter seems a little odd. I’m curious how many people on this board have ever personally given it.

It's a systems error. It mostly depends on the pharmacy's method of entering the drugs into the workstation. If the pharm tech simply has to load the cart based on "look" or "label" with no scanning involved then there is a high risk for error. If there is scanning involved there may be lower, but not nil, risk for error.

 

[sanityonleave]

It's a systems error. It mostly depends on the pharmacy's method of entering the drugs into the workstation. If the pharm tech simply has to load the cart based on "look" or "label" with no scanning involved then there is a high risk for error. If there is scanning involved there may be lower, but not nil, risk for error.

I may be misunderstanding you but this was not pharmacy inappropriately stocking a medication (i.e. dig being in the bupi tray), this was someone reached in the drawer and grabbed dig instead of bupi and drew it up.

Agreed with other posters about individual vigilance, but we know those systems have failure rates no matter how vigilant you are. I agree with other posters, from a systems standpoint -- why was dig stocked in the cart at all? I've never given it or heard of it being given in the L&D OR (or even in the main OR, really) and thus see no reason it should be stocked since it's a high-risk med.

We had an issue where 2cc of concentrated neo (10mg/mL) was given in lieu of 2cc of ondanestron -- after some digging, phenylephrine was the only drug in our top drawer which had very severe harm potential if administered undiluted (50mg/mL ephedrine and 20mg/mL hydralazine, sure, but those are 5-10 fold overdoses versus 250fold overdoses). We moved it to another drawer and finally just got rid of it altogether with premade 80mcg/mL 250mL bags so we didn't need to mix our own.

A tragic accident and an opportunity for both individual and systems-level improvement.

 

[DM27]

So I am very confused. I was only able to skim this, but from reading it the case sounds like she probably got intrathecal digoxin instead of bupivacaine, the C-section was completed uneventfully, and then 60-90min into her recovery stay she manifested all of the symptoms.

...so digoxin provided surgical anesthesia?

 

[Twiggidy]

So I am very confused. I was only able to skim this, but from reading it the case sounds like she probably got intrathecal digoxin instead of bupivacaine, the C-section was completed uneventfully, and then 60-90min into her recovery stay she manifested all of the symptoms.

...so digoxin provided surgical anesthesia?

I was confused about this too. I feel like either A) yes, digoxin must have some ability for nerve block (or nerve destruction). For the patient's sake I hope the latter isn't true. B)The didn't wait long enough to test the level and the first spinal actually worked. 60-90 mins does seem like a long time for digoxin to travel though the CSF but i know nothing about it's specific gravity. Maybe the head was more upright in the C/S and then in RR she was more supine and the digoxin migrated to the brain. All speculation.

 

[IMGASMD]

So I am very confused. I was only able to skim this, but from reading it the case sounds like she probably got intrathecal digoxin instead of bupivacaine, the C-section was completed uneventfully, and then 60-90min into her recovery stay she manifested all of the symptoms.

...so digoxin provided surgical anesthesia?

It was a second dose. So first dose probably worked, just wasn’t fast enough.

 

[DM27]

I was confused about this too. I feel like either A) yes, digoxin must have some ability for nerve block (or nerve destruction). For the patient's sake I hope the latter isn't true. B)The didn't wait long enough to test the level and the first spinal actually worked. 60-90 mins does seem like a long time for digoxin to travel though the CSF but i know nothing about it's specific gravity. Maybe the head was more upright in the C/S and then in RR she was more supine and the digoxin migrated to the brain. All speculation.

It is most likely option B. The few "failed" spinals I have experienced ultimately set in after a range of 20-30 minutes. Whether they were odd responders vs. subdural injections vs. some medication lost during injection I will never know.

It also violates one thing that was pounded into me during residency which was to basically never redo a spinal that "should" have been working without first being able to delay the case 60-90min.

 

[Twiggidy]

It is most likely option B. The few "failed" spinals I have experienced ultimately set in after a range of 20-30 minutes. Whether they were odd responders vs. subdural injections vs. some medication lost during injection I will never know.

It also violates one thing that was pounded into me during residency which was to basically never redo a spinal that "should" have been working without first being able to delay the case 60-90min.

Agree. It's also why I'm typically not a "2nd spinal" person. If the level is "shady" or "not at all" despite what I perceived to be as a normal spinal procedure that's where the syringe full of propofol becomes part of the anesthetic.

I'm playing Tuesday morning QB here, but let's say the "2nd ampule" actually was bupivacaine. Now this anesthesiologists is dealing with 3-4 cc of 0.75% bupiv in the CSF and a definite high spinal. The outcome probably not near as bad "neurologically" (he still would've intubated).

If the spinal isn't right, put them to sleep, maybe slip an LMA if needed, keep dad out of the room until you're done. It's easier to explain and healthy baby / sleepy mom isn't the end of the world (or career).

 

[rakotomazoto]

We had a batch of bupi in the kit not working. Very annoying. Pharmacy claimed bad transportation and storage conditions for the kits.

Ditto. we contacted the manufacturer and they initially said it was nothing, but when we cited all the specific examples of failed spinals, they used the excuse that they must have overheated during shipping, causing the bupivicaine to degrade.

 

[DM27]

If the spinal isn't right, put them to sleep, maybe slip an LMA if needed, keep dad out of the room until you're done. It's easier to explain and healthy baby / sleepy mom isn't the end of the world (or career).

I totally agree. There is a trend in medicine where "usually done this way" is becoming inappropriately synonymous with "required".

 

[IMGASMD]

I totally agree. There is a trend in medicine where "usually done this way" is becoming inappropriately synonymous with "required".

Protocol and standardized care. Are my favorite words.

I know some will say these are good things, until they are not.
Or
It’s a good airway, I am sure I can ventilate. Until I cannot.

 

[coffeebythelake]

Agree. It's also why I'm typically not a "2nd spinal" person. If the level is "shady" or "not at all" despite what I perceived to be as a normal spinal procedure that's where the syringe full of propofol becomes part of the anesthetic.

I'm playing Tuesday morning QB here, but let's say the "2nd ampule" actually was bupivacaine. Now this anesthesiologists is dealing with 3-4 cc of 0.75% bupiv in the CSF and a definite high spinal. The outcome probably not near as bad "neurologically" (he still would've intubated).

If the spinal isn't right, put them to sleep, maybe slip an LMA if needed, keep dad out of the room until you're done. It's easier to explain and healthy baby / sleepy mom isn't the end of the world (or career).

You would LMA a term pregnancy patient?

 

[deleted875186]

I was confused about this too. I feel like either A) yes, digoxin must have some ability for nerve block (or nerve destruction). For the patient's sake I hope the latter isn't true. B)The didn't wait long enough to test the level and the first spinal actually worked. 60-90 mins does seem like a long time for digoxin to travel though the CSF but i know nothing about it's specific gravity. Maybe the head was more upright in the C/S and then in RR she was more supine and the digoxin migrated to the brain. All speculation.

Or maybe his first intrathecal dose was the dig. Failed because it wasn’t bupi.

 

[Twiggidy]

You would LMA a term pregnancy patient?

if it were mid c-section and she says she's feeling things.....yeah. it's no different from those that temporize their "patchy" spinals with midaz, ketamine, and prop, etc

Edit: I know the board answer is to stick in a breathing tube for anyone beyond 12 wks, but there's a lot things we do on the boards that we don't do in practice.

 

[Twiggidy]

Or maybe his first intrathecal dose was the dig. Failed because it wasn’t bupi.

that's true too

 

[caligas]

if it were mid c-section and she says she's feeling things.....yeah. it's no different from those that temporize their "patchy" spinals with midaz, ketamine, and prop, etc

Edit: I know the board answer is to stick in a breathing tube for anyone beyond 12 wks, but there's a lot things we do on the boards that we don't do in practice.

It’s different