Page 52 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

was administered. A delay in diagnosis and treatment

interventions contributed to the patient’s death.

Wrong dose: A patient received 10 times the intended dose of
Neo-Synephrine due to improper dilution and usage of the

wrong syringe size.

Wrong Medication: A paralytic was inadvertently administered
by the anesthesiologist who intended to give lidocaine. Patient

became apneic and required resuscitation.

Contraindicated Medication: A CRNA ordered Toradol out of
habit for perioperative pain relief in a patient with known renal

disease. It was alleged that the patient’s progressive renal

failure and eventual requirement for hemodialysis thereafter
was a result of the Toradol and that the CRNA had failed to

review the patient’s history.

Infusion Line Issues

Medication errors may also be related to the tangle of infusion

and monitoring lines. Consider the following suggestions to
help prevent IV infusion line confusion:

 Trace all lines back to their origin before making

connections (doing so verifies that the correct line will be

joined)

 Lines should be rechecked upon the patient’s arrival in a

new setting or service and at shift changes as part of the
handoff process

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