Drug swap

[IMGASMD]

It’s different

In this case? Or in general?

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[caligas]

In this case? Or in general?

In general, there is difference between giving a little ketamine/Midaz to get through a patchy block VS achieving a depth of anesthesia sufficient to tolerate LMA.

The LMA itself could cause a gagging/coughing response that could be problematic with the gastric contents of a full term parturient.

There is also a medico-legal difference in that using an LMA at term would open you to a battery of criticism supportable by literature.

All that said, admittedly you certainly can give enough IV sedation to lose airway protective reflexes.

 

[IMGASMD]

In general, there is difference between giving a little ketamine/Midaz to get through a patchy block VS achieving a depth of anesthesia sufficient to tolerate LMA.

The LMA itself could cause a gagging/coughing response that could be problematic with the gastric contents of a full term parturient.

There is also a medico-legal difference in that using an LMA at term would open you to a battery of criticism supportable by literature.

All that said, admittedly you certainly can give enough IV sedation to lose airway protective reflexes.

I must admit, gave a few patients with prop after ketamine, versed and fent couldn’t shut them up.....

 

[Southpaw]

It’s different

You’re right. It’s a better airway than jaw thrusting after the versed, ketamine, and propofol. I wouldn’t say it’s something to do routinely, but we shouldn’t have it listed as an allergy either.

 

[deleted875186]

It’s different

Agreed, it’s very different, than giving some sedation.

 

[sevoflurane]

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.

I get that... but the point is risk mitigation. Put the vials that look the same in different places. It’s not rocket science and adds some degree of safety.

For example. Putting Phenylephrine and Zofran next to ea. other is just plain stupid.

You get a sick as faak ruptured AAA with a hgb of 3 and coagulopathic with poor vascular access.... you are busy.

In this case (and many others) that simple thought and execution would have prevented a terrible outcome.

 

[sevoflurane]

 

[sevoflurane]

Human error is a common and predictable denominator. Any efforts to avoid such errors should be undertaken now and not after the fact.

 

[Arch Guillotti]

Everyone needs to read this thread.

This is about all that needs to be said:

1) when something bad happens, it is not the individual's fault. It is the system's fault.

2) we should not try to find the person at fault. we need to change the system

What a load of crap!!! When something goes wrong, you can ALWAYS find the person at fault....I think we need to identify the person, blame the person, and shame that person...so that person can learn from the mistake....including myself.

The speakers were blaming everything from the surgeon to the hospital administration for errors like giving the wrong drug.

It is the person's fault.

 

[sevoflurane]

Everyone needs to read this thread.

This is about all that needs to be said:

Of course it’s the anesthesiologist fault.

Nobody here is arguing that.

But why not create a clinical atmosphere where these wrong drug administrations are difficult to achieve?

Seems like an easy path to risk aversion to me.

Good for patients.
Good for anesthesiologists.
Good for your contracts.

What’s the down side?

 

[nimbus]

I just got home from a risk management seminar which will save me 10% on my malpractice coverage.

THE SPEAKERS WERE SPEWING SO MUCH CRAP, I THOUGHT THEY MUST HAVE SOME KIND OF GI OBSTRUCTION.

They weren't saying anything new.....just the same stuff that I have never agreed with.

1) when something bad happens, it is not the individual's fault. It is the system's fault.

2) we should not try to find the person at fault. we need to change the system

What a load of crap!!! When something goes wrong, you can ALWAYS find the person at fault....I think we need to identify the person, blame the person, and shame that person...so that person can learn from the mistake....including myself.

The speakers were blaming everything from the surgeon to the hospital administration for errors like giving the wrong drug.

It is the person's fault.

Let's hear everyone's opinion on this one.

It’s not a load of crap. We can do both. We can pay better attention to detail AND put systems in place to reduce errors.

Examples of system solutions:
1. bupivacaine included in the spinal kit.
2. Standardized anesthesia drug trays. (we don’t just grab a bunch of different vials from pharmacy and throw them in a bucket at the beginning of a case.)
2. Color coded drug labels.
3. Time out/site confirmation
4. Inspired O2 monitoring
5. Suction

For those who don’t need system solutions, more power to you. I welcome all the help I can get.

 

[nimbus]

View attachment 269252

We got rid of those phenylephrine vials about 10 years ago after a mishap.

 

[sanityonleave]

Of course it’s the anesthesiologist fault.

Nobody here is arguing that.

But why not create a clinical atmosphere where these wrong drug administrations are difficult to achieve?

Seems like an easy path to risk aversion to me.

Good for patients.
Good for anesthesiologists.
Good for your contracts.

What’s the down side?

Thank you for explaining this so clearly. Why 40 years after Tenerife are we still arguing about individual infallibility? (Tenerife airport disaster - Wikipedia)

Unlike a lot of superstars around here, I've made a medication error - when I was a resident, I switched two syringes with exactly the same small white print labels / same size etc. Fortunately the patient did fine and no harm came of the error, but I felt like dog **** for weeks. Obviously my personal vigilance increased, but was I happy when they changed the labels and color coded those syringes? You betcha.

 

[T-burglar]

some would argue that all syringes/labels/vials should purposefully be designed to look similar so you are forced to read the label carefully to determine which drug is which

 

[pgg]

some would argue that all syringes/labels/vials should purposefully be designed to look similar so you are forced to read the label carefully to determine which drug is which

Either all labels white with black print in the same font, or all labels color coded to a universal standard would be better than what we have now, which is a half-assed random combo of color coded and occasional lookalike gotcha vials.

Its the rarity of the doppelganger vials that makes them more dangerous, not the fact that they look alike.

 

[jwk]

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.

Giving a little midaz or ketamine is far different than loading up someone with propofol or other polypharmacy to the point they're obtunded - in which case an ETT is indicated, not an LMA, during a C-section.

 

[jwk]

Either all labels white with black print in the same font, or all labels color coded to a universal standard would be better than what we have now, which is a half-assed random combo of color coded and occasional lookalike gotcha vials.

Its the rarity of the doppelganger vials that makes them more dangerous, not the fact that they look alike.

Most of our commercially pre-filled syringes are color coded but some are not. Some manufacturers color code by concentration or amount, using different colors for the same drug (our dilaudid syringes are like that). Our hospital-made syringes generally are not color-coded. APSF and others have had rigorous debate on the color-coding and whether or not it helps or hurts. For example - all narcs are typically labeled with light blue - but there's a world of difference between fentanyl, sufenta, dilaudid, morphine, methadone, alfenta, remifentanil, demerol etc.

We're changing to Accudose anesthesia carts this fall, so each drug must be removed individually, and a label is printed at the point of use. It will be interesting to see how that fits into our workflow.

 

[MoMoGesiologist]

It’s not a load of crap. We can do both. We can pay better attention to detail AND put systems in place to reduce errors.

Examples of system solutions:
1. bupivacaine included in the spinal kit.
2. Standardized anesthesia drug trays. (we don’t just grab a bunch of different vials from pharmacy and throw them in a bucket at the beginning of a case.)
2. Color coded drug labels.
3. Time out/site confirmation
4. Inspired O2 monitoring
5. Suction

For those who don’t need system solutions, more power to you. I welcome all the help I can get.

I am not a fan of the time out. Instead of the surgeon or one person being responsible it is the right patient, procedure, and side, now everyone is responsible, diluting it down so that basically no one is responsible. Also our time out should have become a checklist of like twenty things, 90% of which I don’t care about.

 

[Twiggidy]

It’s different

True. LMA is more airway protected than nothing but not fully protective.

 

[Twiggidy]

Human error is a common and predictable denominator. Any efforts to avoid such errors should be undertaken now and not after the fact.

Anytime I come on to preach that all drugs should have to be entered/scanned in the the cart before insertion/removal the "I'm a doctor and I'm in a hurry" crowd always shows up. Scanning/entering drugs in the computer dramatically reduces the chance for error because it quite literally makes you double check. It doesn't reduce error to zero but it's a lot better than me hoping the pharm tech wasn't drunk and put the Zofran in the Neo bin. Or that I'm not super sleepy and grabbing digoxin instead of bupivacaine.

We catch errors in our carts all the time.

 

[nimbus]

I am not a fan of the time out. Instead of the surgeon or one person being responsible it is the right patient, procedure, and side, now everyone is responsible, diluting it down so that basically no one is responsible. Also our time out should have become a checklist of like twenty things, 90% of which I don’t care about.

I like it. It literally takes 30 seconds and ensures that everybody is on the same page.

 

[Planktonmd]

I think that intrathecal medications should not be in in the same drawer as IV medications, in other words everything in the Pyxis or Omnicell should be IV medications and preferably not in fatal doses.

 

[Twiggidy]

I like it. It literally takes 30 seconds and ensures that everybody is on the same page.

Exactly. Time outs are good for patient safety

 

[dannyboy1]

In general, there is difference between giving a little ketamine/Midaz to get through a patchy block VS achieving a depth of anesthesia sufficient to tolerate LMA.

The LMA itself could cause a gagging/coughing response that could be problematic with the gastric contents of a full term parturient.

There is also a medico-legal difference in that using an LMA at term would open you to a battery of criticism supportable by literature.

All that said, admittedly you certainly can give enough IV sedation to lose airway protective reflexes.

Agreed. With a little ketamine (20-30 mg) the patient still has protective reflexes, they are just in their happy place. You start with the propofol and they will lose airway reflexes. Placing an LMA is just begging for a lawsuit if things go bad. Just tube em.

 

[Modanq]

Has someone restudied GA anesthesia in the pregnant pt and the risk of failed intubation in the era of all the video tools we have. Isn't the reason the original work on going with spinal in OB was done because DL is bad with all the maternal changes in the airway. I thought that data was from the 80s. Not my area of expertise.

 

[Twiggidy]

Has someone restudied GA anesthesia in the pregnant pt and the risk of failed intubation in the era of all the video tools we have. Isn't the reason the original work on going with spinal in OB was done because DL is bad with all the maternal changes in the airway. I thought that data was from the 80s. Not my area of expertise.

Spinal is mostly for “customer service”. Moms want to see and bond with their newborns. I think you are correct in the sense that today with the advent of video laryngoscopy the “pregnant difficult airway” is a bit overrated.

 

[epidural man]

I feel really bad for this anesthesiologist.

I am also feeling VERY GRATEFUL that our mistakes don't make the newspaper and national news. That is doubly sucky for this team.

I love the idea of a standardized "TOP DRAWER" so that every cart - no matter where I practice - has the exact same thing. Probably 80% of what is used in anesthesia is the same drugs everywhere. Why not standardize it?

I practice anesthesia in 6 or 7 different places. They all are vastly different with regards to where things are placed.

 

[TXEMC344]

That was great. I miss the old days, Jet, Copro, Ventdependent, and the rest of the bunch.

 

[coffeebythelake]

Just saying, especially in stressful situations, pushing the wrong drug can happen really easily.

Reading the label is key. Always read the damn label.

Especially when supervising residents or CRNAs. Especially when you did not draw up drugs yourself.

I held a stick of nicardipine instead of a stick of etomidate in my hand for induction in a cardiac cripple.

I read the label and prevented an inadvertent code situation.

 

[MoMoGesiologist]

Now I’m getting paranoid a resident or CRNA is going to draw up the wrong drug in a mislabeled syringe...

 

[Twiggidy]

Now I’m getting paranoid a resident or CRNA is going to draw up the wrong drug in a mislabeled syringe...

I feel like you have to be paranoid. There’s a fine line between micromanaging and teaching and I the key is figuring out the residents/CRNAs you can trust and the ones that need to be under a microscope

 

[nimbus]

Now I’m getting paranoid a resident or CRNA is going to draw up the wrong drug in a mislabeled syringe...

I’ve always been that paranoid.

 

[MoMoGesiologist]

You won’t know unless you watch them draw up the vial. You can’t be around for all of it...

 

[pgg]

Reading the label is key. Always read the damn label.

Especially when supervising residents or CRNAs. Especially when you did not draw up drugs yourself.

Some years back in my program, a brand new CA1 drew up some phenylephrine in a 10 mL syringe but didn't know to double dilute it. Left it at 1 mg/mL and labeled it that way. Attending grabbed the syringe and pushed a couple ccs. Shenanigans ensued.

They tortured the resident at the M&M anyway. The place was a touch more malignant back then. I'd like to think everyone there knew the score but I still shake my head at the blame deflection.

 

[coffeebythelake]

Thi

Some years back in my program, a brand new CA1 drew up some phenylephrine in a 10 mL syringe but didn't know to double dilute it. Left it at 1 mg/mL and labeled it that way. Attending grabbed the syringe and pushed a couple ccs. Shenanigans ensued.

They tortured the resident at the M&M anyway. The place was a touch more malignant back then. I'd like to think everyone there knew the score but I still shake my head at the blame deflection.

This seems like a shared blame situation. The resident for not knowing standard concentrations and not asking for help. The attending for not reading and verifying.

 

[abolt18]

Thi

This seems like a shared blame situation. The resident for not knowing standard concentrations and not asking for help. The attending for not reading and verifying.

Sometimes you don't know what you don't know. (S)He probably assumed it was standard and didn't know they NEEDED to ask for help. I can tell you, I dilute VERY few drugs in my drug tray. If I picked one up that I hadn't used I'd likely assume it was too be given as is (though I like to think I'd double check).

 

[Twiggidy]

Sometimes you don't know what you don't know. (S)He probably assumed it was standard and didn't know they NEEDED to ask for help. I can tell you, I dilute VERY few drugs in my drug tray. If I picked one up that I hadn't used I'd likely assume it was too be given as is (though I like to think I'd double check).

ive learned to read labels or follow a standard, even if the standard is in "quotes". this came from an instance in residency where I drew up ephedrine in the old "cardiac dilution" of 10mg/cc but I put it in a 10 cc syringe. I think most of use when we dilute the ephedrine vial we use the 10 cc syringe for 5mg/cc dilution. my attending looked at it (even though I labeled it) and said "if you're going to do this put it in a 5 cc syringe that way may brain tells me it's 10/cc and not 5/cc". Now he was using a bad habit, ie, emphasizing that he wasn't reading labels but I still understood where he was coming from.

I also put a double label of a different color on my "strong" pressors which basically tell me "stop for a sec idiot and double check what you're about to give" (1 mg/cc epi, 1 unit/cc vaso, protamine, etc). I think most of these moves are cardiac-isms and I usually caught heat when I did this in general rooms as a resident.

I think if you're covering residents/CRNAs it's prudent just to ask what they drew up and if they're answer is unsure or you don't trust them re-draw the drug. We're not here to make friends, we're here to keep people alive.

 

[epidural man]

ive learned to read labels or follow a standard, even if the standard is in "quotes". this came from an instance in residency where I drew up ephedrine in the old "cardiac dilution" of 10mg/cc but I put it in a 10 cc syringe. I think most of use when we dilute the ephedrine vial we use the 10 cc syringe for 5mg/cc dilution. my attending looked at it (even though I labeled it) and said "if you're going to do this put it in a 5 cc syringe that way may brain tells me it's 10/cc and not 5/cc". Now he was using a bad habit, ie, emphasizing that he wasn't reading labels but I still understood where he was coming from.

I also put a double label of a different color on my "strong" pressors which basically tell me "stop for a sec idiot and double check what you're about to give" (1 mg/cc epi, 1 unit/cc vaso, protamine, etc). I think most of these moves are cardiac-isms and I usually caught heat when I did this in general rooms as a resident.

I think if you're covering residents/CRNAs it's prudent just to ask what they drew up and if they're answer is unsure or you don't trust them re-draw the drug. We're not here to make friends, we're here to keep people alive.

I label my syringes in other ways than using English language words.

In the pain clinic, my skin local - is label with the 25g tiny needle and label it by always using the 5ml syringe. My contrast, I label it by hooking up the pigtail and using the 3ml syringe. The steroid always gets labeled by using the 10ml syringe.

 

[pgg]

I label my syringes in other ways than using English language words.

In the pain clinic, my skin local - is label with the 25g tiny needle and label it by always using the 5ml syringe. My contrast, I label it by hooking up the pigtail and using the 3ml syringe. The steroid always gets labeled by using the 10ml syringe.

What do you do when JC is around?

 

[Twiggidy]

What do you do when JC is around?

I take the day off 😎

 

[deleted162650]

What do you do when JC is around?

Using distinct syringes is actually a JC approved labeling method provided they are used immediately after being drawn up.

 

[IlDestriero]

Now I’m getting paranoid a resident or CRNA is going to draw up the wrong drug in a mislabeled syringe...

I worry about this all the time as well, and usually if I’m giving them a break or something and I need to give non opiates that they drew up, I’ll throw out their zofran, etc. and draw a new one up myself. I’m that paranoid about meds due to the number of times I’ve picked up the wrong vial, syringe, etc. One thing I’m very OCD about is drawing up only one med at a time, and double checking the meds when drawing them up and giving them. That was drilled in on day 1 of residency when we still had high concentration (Neo, etc.) in the carts next to zofran or whatever. There was one trauma case I did as a resident where I gave 100 of Neo and it was obviously 100 of epi that was mislabeled. No harm done, but lesson learned not to trust the meds that others drew up. I also worry about our children’s hospital having different concentrations of some stock meds than the resident’s parent hospitals.

 

[abolt18]

I worry about this all the time as well, and usually if I’m giving them a break or something and I need to give non opiates that they drew up, I’ll throw out their zofran, etc. and draw a new one up myself. I’m that paranoid about meds due to the number of times I’ve picked up the wrong vial, syringe, etc. One thing I’m very OCD about is drawing up only one med at a time, and double checking the meds when drawing them up and giving them. That was drilled in on day 1 of residency when we still had high concentration (Neo, etc.) in the carts next to zofran or whatever. There was one trauma case I did as a resident where I gave 100 of Neo and it was obviously 100 of epi that was mislabeled. No harm done, but lesson learned not to trust the meds that others drew up. I also worry about our children’s hospital having different concentrations of some stock meds than the resident’s parent hospitals.

Funny how a single experience can shape how you do things. Early CA-1, I was helping out a CA-2 in a trauma, GSW to the chest. Attending had asked me to mix up a syringe of vasopressin (1u/mL). When I saw the BP start to sag I handed the syringe to the CA-2 without saying anything (as I was checking blood). The CA-2 proceeded to push the entire stick without looking at the label and handed me back the syringe. For reasons unknown they assumed the syringe I handed them was the antibiotics?????? There were no obvious untoward effects from that bolus, thankfully.

I am extra careful about double checking any drug I push, and now I make sure I vocalize what I'm handing someone, every time.

 

[pjl]

I get that... but the point is risk mitigation. Put the vials that look the same in different places. It’s not rocket science and adds some degree of safety.

Agree.

There was a time when pitocin and zofran had the same color tops and size vials. I took advantage and made our entire hospital Pyxis system change the order of drawers/slots. Now they are all organized by class/effect. For example, all the vasoactive drugs are in a different drawer with things that lower pressure on left, raise pressure on the right. Antiemetics are in the grab bag drawer on the right. Parayltics in a corner far from any other vials like them, etc. No more catching myself picking up phenylephrine vials rather than zofran...

I found if you are actually willing to do the work pharmacy generally doesnt care about where stuff is. I had to convince them to change the slots around on 30 Pyxis machines, but that just required a couple nicely worded emails to pharmacy head and CMO.[/QUOTE]

 

[jwk]

Agree.

There was a time when pitocin and zofran had the same color tops and size vials. I took advantage and made our entire hospital Pyxis system change the order of drawers/slots. Now they are all organized by class/effect. For example, all the vasoactive drugs are in a different drawer with things that lower pressure on left, raise pressure on the right. Antiemetics are in the grab bag drawer on the right. Parayltics in a corner far from any other vials like them, etc. No more catching myself picking up phenylephrine vials rather than zofran...

I found if you are actually willing to do the work pharmacy generally doesnt care about where stuff is. I had to convince them to change the slots around on 30 Pyxis machines, but that just required a couple nicely worded emails to pharmacy head and CMO.

Our drug dispensing machines have individual lockable compartments - no mixing different drugs in the same compartment.

We get drugs from any number of manufacturers and distributors, so we might have three different-appearing vials of the exact same drug at a given time. The vials change, the tops change, the color and size of the printing changes. We're about to get Accudose carts in the OR that will print a drug label at the time you remove each vial. But there is never ever any substitute for reading the label on the vial.

 

[epidural man]

What do you do when JC is around?

Funny thing- The God (don’t you think it’s finny they wanted to be named after a God-like historically figure but makes sure we say “the” in front as to make them more distinguished than the actually JC?) was just here two weeks ago and they didn’t even stop by the pain clinic.