Page 5 - Part 2 Anesthesiology Common Risk Issues
P. 5
SVMIC Anesthesiology: Common Risk Issues
Part Two
Medication Errors
Medication errors were the third most common indefensibility
factor. The types of errors that occurred are outlined in the
following paragraphs.
MAC Anesthesia
The most common errors related to MAC anesthesia are
adverse reaction, wrong dose, wrong medication, and
contraindicated medication.
Adverse Reaction: A patient with a prior penicillin reaction
experienced an anaphylactic reaction after acephalosporin
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.
Page 5
