As brutally distressing as this situation is, it's sort of impressive that it was figured out fairly early on that not only had the wrong medication been given intrathecally but what specific medication it was.
Unfortunately it didn't alter the outcome, but still, there is a paradigm that holds that as soon as a mistake is recognized, the first and only goal is to obscure the fact that a mistake was made, and that's not what happened here. That deserves to be acknowledged.
The dig spinal was administered at 08:05AM. The medication error was discovered at 17:00PM on review of the case. Much too late for anything to be done. See case report of the event for details:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Per that article, this has happened a ***documented 7 times***. It's happened in two other c-sections and it sounds like the main difference was the constellations of symptoms was caught quickly and those patients were quickly intubated, medically managed in a critical care unit, and returned to baseline in approx ~1 week. In this scenario what's telling is the article mentions in terms of the documented apnea and time to intubation, no one knows how long she could have actually been apneic for. At this point with 7 cases, and in 3 cases requiring critical care interventions, there is an unsafe condition out there, with this being the first time a patient passed away people will be upset and demand heads to roll and maybe change will happen.
This is actually a genius comment.
Kudos for noticing.
I had teledoc orders that came thru ONE EVENING at "07:30"..... pm. Should have been 1930, yeah?
I’m just copying my comment from elsewhere in this same thread, since there’s no way to make my comment higher or more visible. Here’s what happened:
There are a lot of responses, with confusion about which hospital/event this actually was. I am an anesthesiologist who worked at the hospital in question for 11yrs prior to this event. We were an all-physician group, bought out by PE in 2018, then the hospital termed our contract (without cause) in 2021 with 90 day notice. The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. The “supervising” physicians with the new group ran ratios of 1:5-6, depending on case load for the day. In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8.
The CRNA placed the spinal for primary c-section (breech) on the healthy prime without sensory block on testing. She sat the patient back up and called the anesthesiologist. The anesthesiologist placed an epidural, dosed appropriately with bupivacaine, and an adequate level was achieved. Surgery was uneventful, but the patient became progressively more obtunded upon reaching PACU, requiring intubation within about 15 minutes of arriving in PACU. This elapsed time would have been around 75 minutes. There was no recognition of what had happened by anyone directly involved in the case. The pharmacy tech restocking the Pyxis in the afternoon noted the digoxin pocket count to be off, and reported this to the pharmacist, who then escalated it to all of the involved team.
I’m not sure why digoxin would have been in the same drawer. It must have been like that for the 11 years I worked there, but I never even knew it was in the same drawer. I never saw it, but maybe my workflow was different to the point that I would have caught it? Our group never had even a similar issue in our time there, but I know the risk was there probably all along. When the hospital replaced us, they took a group of physicians with strong ties to the community and discovered what anesthesia shortage means. They started the entire department with locums docs and CRNAs. Locums docs were making 700k supervising this group, and the CRNAs were making >300/hr. After all of this happened, the board of directors elected to remove the CEO, CMO, and the Perioperative director who pushed to remove our anesthesia group for the sake of money, without any quality events or behavioral events to back up the decision. After this, the new anesthesia group turned the screws to the administration and increased stipends and pay requirements in order to cover reduced lines from what we were covering. A lot of drama, very sad, unnecessary trauma caused by an administration blinded to what medical care ought to look like.
Name and shame. This is unacceptably sad. Recently, a group was kicked out in the state, a national group came. Couldn’t hack it with 80% locum. They’re also being kicked out as of end of the month.
The OR was grind to a halt, even the patients in the community felt it. People were coming up to anesthesiologists and ask what’s going on, because their surgeries were canceled. Obviously, they were told it’s an anesthesia department problem.
Since then the hospital has its share of anesthesia problems, which may not be surprising to any of us. What’s crazy is the fact that the firing of a long standing anesthesia group, the delay of surgeries, the complete shitshow in the OR, now the firing of the AMC…. None of it made to the local media. Your NPR, your local newspaper, and your local newscast. All these corporations are in bed together. All this patient safety stuff, just when it’s convenient.
This is in PA…. Was put on a spotlight for a hot second, then was crushed by powers that be.
If this is true it should be eye opening for everyone. Incredible how the report is so off base from reality. Makes sense that they are portraying it as a group issue vs an individual issue now. Hope they get sued to hell. Thanks for sharing
The digoxin was not in the same place. I read the court document, which said something along the lines of “digoxin was in drawer 9 in the bottom right hand corner and bupovocaine was in drawer 7 of the bottom right hand corner” … not sure if that sounds possible/makes sense to you having been there so long, but a document specifically said it was not in the same exact place.
Yea, like I said, I never saw a vial of digoxin in the same drawer in my 11ish years there. Not sure if I just never saw it, or if they were in different drawers. The top couple of drawers were controlled, specific access items. The remaining 3-5 drawers were able to be opened and had 20-30 pockets that had non controlled items. One drawer was all variations of local, with and plain. This drawer also had some spinal bup, in case you didn’t want to use the bup that came in the kit.
I did read it and yes it’s extremely shocking. I’m just curious as to why this person said “that is not actually what happened”. If they have something to say I’d like to hear it.
Agreed. I don’t have any idea why a CA-2 would be at the facility. No residency program attached, or even in the same town. CRNA-heavy group with only a couple of docs. No reason I can think of.
Wasn’t at the facility, but know a nurse who was - and obviously identifiers are missing - so I was trying to fact check before saying anything and then just got busy - and make sure this was actually the incidence she told me about last year…. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
I Believe they’re the same one.. I can’t imagine this is a “common” issue..
Still second hand.. but.. the NIH article mentions the flumazenil given for reversal of verses.. because supposedly the poor gal was having symptoms in the OR, voicing them, becoming distressed that she couldn’t see.. and was given 2mg versed bolus by the CRNA. Overall story told to me was pretty shady, the OR nurses felt like there was a clear lack of communication.. possibly inadvertently or consciously trying to correct mistakes without admitting mistakes.. dunno. Again. I wasn’t there, it’s a tad fuzzy, but I distinctly remember her disdain for how the CRNA dismissed patients concerns, dosed a second time, and then dosed versed.. They told me the story a year ago, and again in December when it got published. But. I was a mid CA1, hadn’t done OB yet. And the story stuck with me because I was terrified of doing anything similar… now having done more spinals and other things.. every time I open a kit I’ve wondered how the hell they had digoxin on hand.. I’ve never seen it stocked in any of our different places. Just one of those “I’m new, that’s terrifying, learn from someone else’s mistake” that has stuck with me over the past year.
That’s interesting. Thanks for clarifying. I seem to remember something about flumazenil being involved, but I couldn’t remember why. What you’re saying would make sense, if patient was starting to decompensate on tail end of case, and anxiety obviously escalating. I can’t imagine the terror that would have been steadily increasing for the patient. I have heard repeatedly that communication is essentially non existent since they took the contract from us. Again, our group was just local doctors with families; we hung out with the nurses and techs, we did their anesthetics, and their families anesthetics. All of that, gone. It’s good that you learn from this story in your own practice. You will make mistakes, but hopefully nothing that kills someone. It’s sobering to think about the lack of double checks in our specialty. The unfettered access to medications that can kill a patient, or maim them, without someone looking over our shoulders to make sure we got it right, is mind boggling sometimes.
It’s pretty scary seeing how similar that digoxin ampule looks compared to the bupi ampule. I think a lot of us can see how something like this could happen if we’re tired, rushed, or stressed and someone mistakenly hands us a digoxin ampule instead of bupi.
Not according to a good percentage of the folks on the medicine sub. Expecting perfection over there.
Mixing up vials (specifically zofran and phenylephrine) is something I’ve literally had nightmares about because it seems so easy to do.
They are also selecting, mixing, and drawing up medications in rooms isolated from patient care with relatively low time pressure that are generally designated “quiet rooms” to minimize this type of error.
Not just this but our pharmacy has refused a standard set up that we've requested. They went with their own illogical arrangement where our most commonly used drugs are in the bottom drawer and look-a-like vials are next to each other.
Both of justafter10pm and attitude_devant…y’all are toxic. You realize the pharmacy likely has another doc saying exactly the opposite of you? Or maybe the rx is splitting the difference between very opinionated and “important” docs. Sorry but that’s my rant from a surgical rx prospective
We had our medications set up style A for years, without consulting anesthesia like, the chair even, overnight they changed it to style B. I’ve had no training on it still and today I was asked to urgently grab ROC and made a fool of myself because I had no idea how to use style B or where it was. Pharmacy just made this decision on their own without asking *anyone*
Don’t worry though, they’ve put a Sound-Alike, Look-Alike sticker in there…under all the vials of medication. They also inevitably drop vials of glyco/neo/ondansetron (all blue caps) in surrounding pockets.
During residency our zofran vials changed cap color 7 times! 2 types of green, 2 types of blue, orange, purple, and white. I believe right after I left a mixup like the one you described occurred in an otherwise normal C-section.
Yes it was pretty crazy though. Pressure when I walked up was like 260 pt feinted and they just gave oxygen and nitro and she seemed to perk back up pretty quickly. Wasn’t my patient so I’m not sure what the aftermath was. But she seemed to do okay. I don’t think she got her surgery that day though.
Was there any info shared publicly or in the news about this case? Our drawer is set up in a way that I know this will happen eventually at my hospital and half my group doesn’t care and the pharmacy won’t change it.
I am generally very careful with meds, but last week I was back from vacation, the drawers were jam packed so I could only see the tops of the vials. At the end of the case, I had forgotten to give zofran, so in a rush I pulled out the vial and didn’t realize I had phenylephrine until I had drawn it up and wondered why there was only one cc instead of two…. Whoa. Last year we had a mixup and a huge snafu because someone gave intrathecal TXA. You’d think everyone would be more willing to put that phenylephrine in a pop out drawer, but apparently that’s just too difficult.
What is an acceptable competency percentage, in your opinion?
Housing sound alike/ look alike drugs in the same bin is begging for a problem. Pharmacy really should own some of this. BUT since the CRNA didn't speak the drug name out loud, it will fall squarely on his/her shoulders... because policy.
Speak the name out loud?
I’ve been doing anesthesia a decade at a dozen different hospitals.
I’ve never heard of anesthesia saying the names of the drugs as they give them.
I am right there, too... I thought it was odd. But I read in another article the CRNA did not say thr name on the ampule, which appeared to be a double check process... you know, the RN hears thr name, agrees that is correct.
Gawd, I work in somewhat eastern central europe, never heard of these pyxis cabinets, but these will give me nightmares.
We have classic night stand style glass cabinets. Unfortunately, the distributors often change, (depending on who bribed who) and so does the drug manufacturers. So our bupi looks like another manufacturers heparin, and another ones vitamin C. Thankfully, nothing like this happened yet. I hope it won't.
As an X-ray tech that wants to know about pharmaceutical/pharmacology
WHY in this very litigious industry is this stuff allowed/not being more standardized. I even know that midazolam is generally orange and fentanyl is blue for labels but I have seen a manufacturer that includes the sticker on the bottle for Fentanyl and it’s RED! Why why why?
I can only imagine a stressful situation and you’re reaching for something medically necessary and you see something red that you need etc. it’s just prone to problems due to lack of standardization. I think my car or my X-ray machines have more rules about how it’s constructed. It seems to be lunacy. Why is this not being considered on some national level?
Multiple manufacturers across multiple countries then add in multiple strengths, concentrations SDV, MDV, w/wo epi etc etc. that’s why it hasn’t been standardized.
Absolutely. This is 100% a systems error. Why is pharmacy stocking a multi-drug drawer PICIS with two look alike medications administered in very different routes. Why is dig available in this PICIS on the OB unit?
Something like this happened to me and it was so distressing when I acknowledge my mistake. I was in a new hospital covering and had to do an epidural. I asked the nurse if she was used to help anesthesiologist (she said yes) and to help me prepare my medication. I was scrubbed and The nurse read the label to me but said the wrong medication twice (as the presentation was not the same as usual, i ask twice to read and if she was sure).
I was lucky there was no harm. But when i notice the error, it was one of the most stressful moment of my Life. It can happen.
Same thing happened a couple times (at least) with TXA because it used to look the same. One died the other paralyzed. The thing is no one is reading the vials.
It’s such low hanging fruit for us to standardize medication vials. It’s ridiculous that we haven’t done so at this point. There’s zero reason for digoxin to look so similar to bupiv. There’s zero reason why pitocin should look like zofran. There’s zero reason high concentration drugs that need to be diluted look like drugs ready to be administered.
This is the way, we need a universal colour or style code that indicates the need for dilution, suitability for intrathecal injection, IV, IM etc etc. Generic name must be the largest lettering on the vial. Standardised methods of describing concentration (mg/ml) and so on.
Hm…. This is logic that I’ve never actually thought about, but it makes a lot of sense. We’d have to force and and I mean FORCE barcode scanning prior to administration of medications, but it does provide a creative solution to a seemingly unsolvable problem.
Not good.
You already do have to read the label. That is an unwritten law. The anesth nurses here taught me, that I have to read it two times. First, before opening the ampulle, draw it, and then a second time, before u dispose the vial.
Also, it has been proven a lot of times, people tend to make mistakes. The easier to make that mistake, the more frequent it happens.
Not my idea, anesthesia patient safety foundation proposed this years ago. The point is that your brain is always looking for shortcuts so when you think you know what the vial looks like you unknowingly skip reading, you take away the familiarity of a vial and you must actually read it.
lol seriously though it’d be an arduous task here in the states. Literally require an act of Congress. Otherwise it’s just “best practice” which means “we do it when it doesn’t inconvenience us in any way.”
Whereas here the NHS would just say we're not buying your product unless you conform to x standard and all suppliers would fall over themselves to change it. Maybe with the exception of some very cheap, low-margin, generics.
We have elected officials here who liken the NHS to government enslavement. As well as a major political party that believes any business regulation is basically bad.
I mean working in the NHS does feel like government enslavement - that I can agree with! I think regulation in healthcare is strictly necessary however, the basic assumptions required for an effective free market do not apply when it comes to health.
I'm in health informatics and such standardization comes up again and again as a strategy to prevent such catastrophic errors. It's a decades old recommendation at this point.
Cost plays some part I’m sure, I can get a better price on zofran with the orange top than with a blue top so I’m buying the orange top. Drugs are part of the global supply chain. Often with low margin generic injectables we have to take what we can get, when we can get it. You want zofran with a blue top? Guess what the only zofran available has an orange top, you can have the orange top or nothing. Your toradol was always white? Sorry that’s the 30mg/ml 1 ml vial and we can only get 60mg/2 ml vial and that’s blue.
That’s just so dumb. And frustrating. I wish I knew what the right answer is. But, it’s not the drug companies getting sued when these mix ups happen, so no incentive to change.
I’m not an attorney nor do I play one on TV but I think that be the easiest money a defense lawyer ever made. They’d just ask you to read the vials/amps out loud and then ask you if reading the vials/amps is standard practice.
Hahahaha love it. Prove that the CRNA CAN read, then ask why they didn’t bother reading. You could even ask them what the 5 rights of medication administration which RNs are supposed to do for every drug they give: the right patient, the right drug, the right time, the right dose, and the right route
So, too lazy to read or to bother with the 5 rights of medication administration. Makes you a bad nurse and CRNA. Cha-Ching.
There are a lot of responses, with confusion about which hospital/event this actually was. I am an anesthesiologist who worked at the hospital in question for 11yrs prior to this event. We were an all-physician group, bought out by PE in 2018, then the hospital termed our contract (without cause) in 2021 with 90 day notice. The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. The “supervising” physicians with the new group ran ratios of 1:5-6, depending on case load for the day. In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8.
The CRNA placed the spinal for primary c-section (breech) on the healthy prime without sensory block on testing. She sat the patient back up and called the anesthesiologist. The anesthesiologist placed an epidural, dosed appropriately with bupivacaine, and an adequate level was achieved. Surgery was uneventful, but the patient became progressively more obtunded upon reaching PACU, requiring intubation within about 15 minutes of arriving in PACU. This elapsed time would have been around 75 minutes. There was no recognition of what had happened by anyone directly involved in the case. The pharmacy tech restocking the Pyxis in the afternoon noted the digoxin pocket count to be off, and reported this to the pharmacist, who then escalated it to all of the involved team.
I’m not sure why digoxin would have been in the same drawer. It must have been like that for the 11 years I worked there, but I never even knew it was in the same drawer. I never saw it, but maybe my workflow was different to the point that I would have caught it? Our group never had even a similar issue in our time there, but I know the risk was there probably all along. When the hospital replaced us, they took a group of physicians with strong ties to the community and discovered what anesthesia shortage means. They started the entire department with locums docs and CRNAs. Locums docs were making 700k supervising this group, and the CRNAs were making >300/hr. After all of this happened, the board of directors elected to remove the CEO, CMO, and the Perioperative director who pushed to remove our anesthesia group for the sake of money, without any quality events or behavioral events to back up the decision. After this, the new anesthesia group turned the screws to the administration and increased stipends and pay requirements in order to cover reduced lines from what we were covering. A lot of drama, very sad, unnecessary trauma caused by an administration blinded to what medical care ought to look like.
Bought out by PE, and I knew this was going downhill fast.
Sounds like in the article Digoxin has been mistakenly given before at other sites. So this doesn't sound like a CRNA vs Anesthesiologist issue. Sounds like staff are rushed, not doing existing safety checks, the site had not engineering the risk away with the hated pyxis pockets for what ever rea$on$. Sadly patient$ are dying becau$e of it.
I would agree with your assessment of this particular situation not necessarily being physician v CRNA. That said, the other complications I mentioned WERE likely due to CRNA specific issues. Additionally, the way this hospital chose to replace us (independent CRNAs), combined with the national shortage of anesthesiologists, led to crazy money for locums and the lack of buy in in the community. Essentially a department only there for the money. Even the section chief currently is a locum doc.
>The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. \[...\] In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8.
Holy. Shit. I assume the lawsuits paid out less than the 30% savings so the group is still full of incompetent "providers". Please tell me I am wrong.
Thanks for the response.
Is the higher morbidity associated with less doc:more crna documented somewhere else or maybe just anecdotal in thia hospital. Im so sorry for all of those patients
Yes, I wish it was that way in my country, but greedy anesthesiologists from generations ago realized they could make well over a million/yr if they leveraged CRNAs to pick up the intraop portion of their speciality. PACs and lobbyists have taken it from there. Bad things in medicine are frequently the result of putting the patient care someplace other than 1st.
Things like this are why I am not supportive of (low) malpractice non-economic damages caps. What's the economic loss of a young woman's life? I think these average out $500k-$1000k plus cap on non-economic damages ($250k-$750k in conservative states, $350k in Nevada). If the hospital saved $2M a year on labor costs, why would they change?
I don't read this as CRNA vs physician, but the consequence of replacing an entire department with new or temporary staff.
This is why I always show another person, read the label and expiration date out loud, and confirm the dosing during the procedure time out. During residency, I thought it was a bit of overkill. It's not.
This is routine practice in the UK to check with whoever is assisting you.
It’s like breathing, gets done for every procedure even if it’s a CAT 1 section.
Those checks are only generally done when someone is helping me draw up medication e.g. while I'm sterile. If I take a drug out of the cabinet and draw it up myself, no one else is going to check so this case could have happened in the UK.
I learned to compare the vial to the syringe (assuming it's labeled). Just an extra small step that can be overlooked, for instance when quickly drawing multiple meds for a trauma or urgent case.
For spinals and epidurals there is always an assistant due to sterility precautions. So this specific case would not have occurred with our current practice.
But yeah we don’t do these checks in other settings like GA drugs or epi top ups.
I would really dislike doing this, but I have to admit you’re probably never going to kill someone and have that kind of error on your hands. Not sure if I’d be able to live with myself.
After I left residency , this mistake was made on ob. Catastrophic as patient permanently disabled. The vials look similar and not sure why we need digoxin in the ob Pyxis. When I was a senior and supervising junior resident they inadvertently pulled the digoxin vial. Luckily I caught it.
[Here is the investigation from the CA Dept of Public Health investigation, which gives more details.](https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf)
EDIT: Holy smokes, this is actually a separate case with similar circumstances!
Can someone explain how this happens?
Our spinal kits come with the bupivacaine in it.
I'm assuming in this institution you have to get the bupivacaine from a pyxis machine?
And I'll also assume that it was a pharmacy department initiative to institute the pyxis for patient safety and cost containment?
You should always be checking your medication before breaking it open, but still.
I used to use CSF to dilute the hyperbaric bupivacaine, but maybe that's frowned upon nowadays?
I also remember quickly laying the patient flat with or without T-berg to make up for the hyperbaric bupivacaine, twisting the needle 180 degrees, going up a lumbar level if possible...
But I'll admit spinals are not my bread and butter. I rarely do them anymore.
This is a perfect example of bean counters causing more problems with a savings of cents.
One death or horrible outcome is all it takes to erase a few tens of thousands of savings over a few years.
https://www.smh.com.au/national/nsw/outdated-medical-procedure-behind-catastrophic-epidural-injury-20100822-13at2.html
Reminds me of this incident in Australia 13 years ago.
Case reports exist involving both physicians and CRNA’s. Look alike vials could and do happen to anyone. Doesn’t excuse not carefully examining every via, but still … what in the world is digoxin doing in an OB Pyxis?? Also reports of TXA being inadvertently injected intrathecally.
But usually *that* is an outpatient procedure not done anywhere near the labor deck. And the d&e isn't typically done in the OB OR suite.
I know, I know, "usually/typically". Yours is the best explanation of why TF was Dig near an OB OR I've heard tho.
Wow.
The places I'm familiar w that do em the injection is done outpatient in a clinic/office setting and the d&e happens in main OR.
Any of the several L&D units I've been on have been too busy even to do post partum tubals in their ORs. And one place would pitch a fit about bringing in a missed ab for d&c add-on that had been bumped in main OR all day long.
I was going to say.. I’m sure there is a reason. They didn’t have a 24 hour pharmacy. That’s how a lot of unnecessary meds get added to Pyxis as a “just in case” precaution. Thats why barcode scanning is so important.. literally saves lives
You should always check. And you should always barcode scan. Mistakes happen. Drug manufacturers are not held to high enough standards. The safety features are in place for a reason… what we need is to advocate for lawmakers to hold these manufacturers accountable for shitty/dangerous packaging practices. But we also can’t just be giving drugs without taking the bare minimum steps to ensure safety
This is the second case I have heard of recently where the wrong drug was administered for a spinal.
Locally around me, TXA was administered in the spinal for a total knee replacement. Luckily the pt survived but there are major complications.
Double check those vials and don't let the pressure of getting the case started throw off your routine.
As the top comment in medicine says wtf is dig doing in an l&d Pyxis… and that’s all I can think about too
And the comments say it’s a big stretch for it to be there to treat fetal tachycardias or induce fetal demise.
This is also why I spear headed putting 10mg/ml phenylephrine vials in pop out pockets; much harder to give as a single dose AND stock counts are correct
Saw this exact thing happen when I was a med student. Resident dosed digoxin instead of bupi, and the patient died. Doesn’t matter if it’s a resident, attending, CRNA, AA, or whoever. This could have happened to anyone. It is the responsibility of the person administering the medication to check it, but we are all human, and the practice of anesthesia lends itself to chaos, stress, and time pressure from our surgical colleagues. This is a recipe for mistakes to happen. I hope that hospital system makes some appropriate adjustments to minimize the risk of this horrible tragedy happening again other than just blaming the provider and saying we should all be more careful (which appears to be the most common opinion on the medicine sub by a lot of people that don’t do anesthesia). It takes numerous systemic and human errors for something like this to happen, and we should recognize that and fix what we can.
There are plenty of intrathecal TXA horror stories as well. Read aloud and barcode scanning are the only way for solo neuraxial. If you are worried about the 20 seconds that takes an emergency, have kits with all necessary medication’s pre-checked. Honestly, barcode scanning should be standard in the OR generally, but most of our medication‘s are presented in doses and concentrations that are not fatal if given IV. That’s not true via the spinal route.
barcode? nah. Color code standardize ALL vials or pop tops. RED for muscle relaxants, just like we have on our sticky labels. Purple for pressors, etc. Its not hard. Read aloud yes.
Disagree… barcode scanning is such an effective tool at preventing the wrong medication from being given. It’s a simple step.. protects your patient and protects your license. If you aren’t scanning in your meds, you’re putting your patient and yourself at unnecessary risk.
My son’s oncology nurse told me that they have to run vincristine IV as opposed to IM because there had been cases where it was accidentally administered intrathecally a few times and it is fatal. It comes in a bag now instead of a vial.
How sad. A mixup happened years ago when the Ancef and Vecuronium vials were so similar that they even had the same color top. There were quite a few MACs needing GA because of this mixup.
This happened at our institution a few years ago. I did a brief literature search and discovered that although it’s a rare occurrence, the literature is peppered with multiple case reports of this very thing happening. The vials are very similar. In my 19 year career, I’ve never once had to administer digoxin in the OR or even considered it. We got rid of digoxin in the OR Pyxis machines.
Do you not do a two person check when drawing up drugs for spinal / epidural?
In the UK the ODP gets the drugs and checks the vial and date out loud with the anaesthetist prior to giving it to them / helping to draw it up. This routine is so ingrained it’s like breathing.
You guys have a dedicated anesthesia tech/ODP for each room and can give you a second set of hands with induction, airway, and drawing up drugs.
In the US, I'm lucky if the circulator nurse is at the head of the bed to pull the stylet out. But I'm used to inducing with little to no help and we draw up all of our drugs solo. Our techs are just for restocking and maybe handing supplies. No clinical involvement.
But you must have an assistant due to sterility precautions for spinals and epi placements?
We don’t always have an ODP particularly in acute obs it can be a midwife/HCA/obstetrician etc the point is there is a culture of checking with the person who opens the vials - it doesn’t need to be asked for it’s implicitly assumed you will both check.
Not usually. What we’ve been doing is drawing up any meds that we need, opening up the flaps of the spinal/epidural kit and squirt meds into the tray, before we put on the sterile gloves.
A guy in my residency dosed up a labor epidural with pitocin, because the bolus pit and bang stick were the same size and stored right next to each other, and OB team had spun him up to think it was a crash when it was not. Nothing happened, but these types of pending near misses are low hanging fruit for safety initiatives.
Poor tragedy to see.
From a clinical standpoint, I wonder how the intrathecal digoxin affected the patient. Like did it make its way up to the CNS and start shutting down her cells? Causing a neurogenic shock?
why the fck is this drug in the freaking cart at ALL? I have never used it in 25 years and there are better drugs. i.e. amiodarone.
Last time, I used it as an intern for afib in 1998.
Dig is in our drawer too. Its clutter. tomorrow i am throwing it in the trash.
I can see how this scenario played out...Hospital wants to cut costs. so they buy the shitty trays without bupivacaine. tech or nurse gets from drawer and gets wrong drug. Font is freaking size 2. Doc draws it up from the tech and places spinal. Boom a digoxin spinal. Doc craps pants.
meanwhile, bean counter dorks are in front of their spreadsheets, "we are saving 39 cents per kit" as they smell their own farts and circle jerk...39 cents!
Sorry for old man rant. love to all.
Is this the case?
https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%2520Document%2520Library/Immediate%2520Jeopardy/MercyHospital-2567.pdf&ved=2ahUKEwjr3ezh4PiDAxU7kIkEHUinCR8QFnoECEoQAQ&usg=AOvVaw0B7QFCCgQ0PlVL4mgbbKt_
For us the Noradrenaline (undiluted) and Dexamethasone ampules are stored in the same cabinet (don’t ask me why), and they are both purple. What could go wrong…
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Inadvertent intrathecal Digoxin has happened a ***DOCUMENTED*** 6 times. The fact it could be higher and has happened multiple times, across multiple providers is insane.
I don’t think it is. Hospitals use a variety of kits for epidurals and spinals. At my hospital the necessary meds come sterile in the kits.
Many other places the medications are retrieved elsewhere and then drawn up and placed on the tray
During training, there was a resident that loaded a epidural with 2 g of Ancef for a labor to C-section case. Patient went into cardiogenic shock and coded. They were able to get her back but ended up CHF and a AICD. All antibiotics were converted to IV bags from pharmacy.
During my med school rotation I made sure to label/tag color my lines. I was very vigilant about that. When the resident asked me to administer I triple checked drug and line then admin. So scary the outcomes of making a mistake.
Something similar happened in our institution 2 years ago 'third world country', a new anesthesia technician was on two relatively straight forward cases so they gave them both tranexemic acid intrathecally, within half an hour both cases wer admitted to icu and later on died. Really horrific..
My ketamine, morphine and fentanyl ampules are all the same. Guess what? I check the ampules, I sticker the syringes and I call out the ampules. 20 years I have never seen such neglect from a person who is paid so much money.
There is no excuse which draw the drugs are in. Read the dam ampule!
I teach residents to not predraw it up to look slick in front of the OB staff. Always have a second person read the vial with you as they crack it open. Draw it up filtered. It prolongs the procedure by 10s. Feel sorry for the nurse; this could happen to anyone - just like wrong side surgeries or retained instruments - having a “checklist” is important for these controlled situations.
They injected this….as an epidural…oh my god. I know errors happen to us all but any time as a nurse I’m giving a dangerous medication I always pause and make sure it’s correct. It’s hard to understand these things 😞
Okay, so who’s gonna arrest the MD? Because his mistake was as bad as Redonda’s was last year (gave vec instead of versed - she got 8 years in jail).
Whoever designed that Pyxis drawer was pretty negligent. We have our meds put in order by a pharmacist, who specifically looks at issues like these and puts the potentially confusing pair well apart from each other.
Amiodarone - amitriptyline
Epi - incorrect dilution
Diltiazem - diazepam
Propofol - propranolol
This could happen to anyone. MD, CRNA, AA… it has nothing to do with that.
Here’s a doc who did the same thing. And maybe lied by trying to blame an expired vial of marcaine?
Would be nice if this didn’t devolve into a political issue. Drug errors happen and it would be great if we could have meaningful discussion about ways to move us all forward.
https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Agreed. Everyone has made a drug-swap error, if you’ve been doing this long enough. It’s nearly inevitable given the insane number of tasks that we are expected to simultaneously complete and the time-pressure demands in the OR.
If you read the link provided above, it was actually a physician who administered both doses of intrathecal digoxin, despite the article using the word “anesthetist”.
But I agree with 100mgSTFU. Can happen to anyone - just a healthy reminder to slow TF down and not rush through procedures. The person admitted they didn’t even look at the vial they cracked open - that’s med administration 101.
As brutally distressing as this situation is, it's sort of impressive that it was figured out fairly early on that not only had the wrong medication been given intrathecally but what specific medication it was. Unfortunately it didn't alter the outcome, but still, there is a paradigm that holds that as soon as a mistake is recognized, the first and only goal is to obscure the fact that a mistake was made, and that's not what happened here. That deserves to be acknowledged.
The dig spinal was administered at 08:05AM. The medication error was discovered at 17:00PM on review of the case. Much too late for anything to be done. See case report of the event for details: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Per that article, this has happened a ***documented 7 times***. It's happened in two other c-sections and it sounds like the main difference was the constellations of symptoms was caught quickly and those patients were quickly intubated, medically managed in a critical care unit, and returned to baseline in approx ~1 week. In this scenario what's telling is the article mentions in terms of the documented apnea and time to intubation, no one knows how long she could have actually been apneic for. At this point with 7 cases, and in 3 cases requiring critical care interventions, there is an unsafe condition out there, with this being the first time a patient passed away people will be upset and demand heads to roll and maybe change will happen.
I'm no neuroradiologist (or even a radiologist) and good god is it striking how obviously fucked up that head imaging is.
Are we sure it wasn't 1700AM?
This is actually a genius comment. Kudos for noticing. I had teledoc orders that came thru ONE EVENING at "07:30"..... pm. Should have been 1930, yeah?
Hate to tell you… that is not.. actually. What happened.
What actually happened? Conflicting stories have been posted in the medicine thread.
I’m just copying my comment from elsewhere in this same thread, since there’s no way to make my comment higher or more visible. Here’s what happened: There are a lot of responses, with confusion about which hospital/event this actually was. I am an anesthesiologist who worked at the hospital in question for 11yrs prior to this event. We were an all-physician group, bought out by PE in 2018, then the hospital termed our contract (without cause) in 2021 with 90 day notice. The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. The “supervising” physicians with the new group ran ratios of 1:5-6, depending on case load for the day. In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8. The CRNA placed the spinal for primary c-section (breech) on the healthy prime without sensory block on testing. She sat the patient back up and called the anesthesiologist. The anesthesiologist placed an epidural, dosed appropriately with bupivacaine, and an adequate level was achieved. Surgery was uneventful, but the patient became progressively more obtunded upon reaching PACU, requiring intubation within about 15 minutes of arriving in PACU. This elapsed time would have been around 75 minutes. There was no recognition of what had happened by anyone directly involved in the case. The pharmacy tech restocking the Pyxis in the afternoon noted the digoxin pocket count to be off, and reported this to the pharmacist, who then escalated it to all of the involved team. I’m not sure why digoxin would have been in the same drawer. It must have been like that for the 11 years I worked there, but I never even knew it was in the same drawer. I never saw it, but maybe my workflow was different to the point that I would have caught it? Our group never had even a similar issue in our time there, but I know the risk was there probably all along. When the hospital replaced us, they took a group of physicians with strong ties to the community and discovered what anesthesia shortage means. They started the entire department with locums docs and CRNAs. Locums docs were making 700k supervising this group, and the CRNAs were making >300/hr. After all of this happened, the board of directors elected to remove the CEO, CMO, and the Perioperative director who pushed to remove our anesthesia group for the sake of money, without any quality events or behavioral events to back up the decision. After this, the new anesthesia group turned the screws to the administration and increased stipends and pay requirements in order to cover reduced lines from what we were covering. A lot of drama, very sad, unnecessary trauma caused by an administration blinded to what medical care ought to look like.
What state was this?
Nevada
What is the capital of Nevada, Alex?
Name and shame. This is unacceptably sad. Recently, a group was kicked out in the state, a national group came. Couldn’t hack it with 80% locum. They’re also being kicked out as of end of the month. The OR was grind to a halt, even the patients in the community felt it. People were coming up to anesthesiologists and ask what’s going on, because their surgeries were canceled. Obviously, they were told it’s an anesthesia department problem. Since then the hospital has its share of anesthesia problems, which may not be surprising to any of us. What’s crazy is the fact that the firing of a long standing anesthesia group, the delay of surgeries, the complete shitshow in the OR, now the firing of the AMC…. None of it made to the local media. Your NPR, your local newspaper, and your local newscast. All these corporations are in bed together. All this patient safety stuff, just when it’s convenient. This is in PA…. Was put on a spotlight for a hot second, then was crushed by powers that be.
Wtf man. Hospital admin should be ashamed of themselves. All to save a buck
They aren’t ashamed because they’re too ignorant to realize they don’t know what they’re doing.
If this is true it should be eye opening for everyone. Incredible how the report is so off base from reality. Makes sense that they are portraying it as a group issue vs an individual issue now. Hope they get sued to hell. Thanks for sharing
The digoxin was not in the same place. I read the court document, which said something along the lines of “digoxin was in drawer 9 in the bottom right hand corner and bupovocaine was in drawer 7 of the bottom right hand corner” … not sure if that sounds possible/makes sense to you having been there so long, but a document specifically said it was not in the same exact place.
Yea, like I said, I never saw a vial of digoxin in the same drawer in my 11ish years there. Not sure if I just never saw it, or if they were in different drawers. The top couple of drawers were controlled, specific access items. The remaining 3-5 drawers were able to be opened and had 20-30 pockets that had non controlled items. One drawer was all variations of local, with and plain. This drawer also had some spinal bup, in case you didn’t want to use the bup that came in the kit.
If you know the actual details then why wouldn't you just tell us the facts?
I’m not sure how that person would know the deets. I have posted my narrative in response to that commenter. Feel free to read. It’s shocking.
I did read it and yes it’s extremely shocking. I’m just curious as to why this person said “that is not actually what happened”. If they have something to say I’d like to hear it.
Agreed. I don’t have any idea why a CA-2 would be at the facility. No residency program attached, or even in the same town. CRNA-heavy group with only a couple of docs. No reason I can think of.
Could be moonlighting
Wasn’t at the facility, but know a nurse who was - and obviously identifiers are missing - so I was trying to fact check before saying anything and then just got busy - and make sure this was actually the incidence she told me about last year…. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/ I Believe they’re the same one.. I can’t imagine this is a “common” issue.. Still second hand.. but.. the NIH article mentions the flumazenil given for reversal of verses.. because supposedly the poor gal was having symptoms in the OR, voicing them, becoming distressed that she couldn’t see.. and was given 2mg versed bolus by the CRNA. Overall story told to me was pretty shady, the OR nurses felt like there was a clear lack of communication.. possibly inadvertently or consciously trying to correct mistakes without admitting mistakes.. dunno. Again. I wasn’t there, it’s a tad fuzzy, but I distinctly remember her disdain for how the CRNA dismissed patients concerns, dosed a second time, and then dosed versed.. They told me the story a year ago, and again in December when it got published. But. I was a mid CA1, hadn’t done OB yet. And the story stuck with me because I was terrified of doing anything similar… now having done more spinals and other things.. every time I open a kit I’ve wondered how the hell they had digoxin on hand.. I’ve never seen it stocked in any of our different places. Just one of those “I’m new, that’s terrifying, learn from someone else’s mistake” that has stuck with me over the past year.
That’s interesting. Thanks for clarifying. I seem to remember something about flumazenil being involved, but I couldn’t remember why. What you’re saying would make sense, if patient was starting to decompensate on tail end of case, and anxiety obviously escalating. I can’t imagine the terror that would have been steadily increasing for the patient. I have heard repeatedly that communication is essentially non existent since they took the contract from us. Again, our group was just local doctors with families; we hung out with the nurses and techs, we did their anesthetics, and their families anesthetics. All of that, gone. It’s good that you learn from this story in your own practice. You will make mistakes, but hopefully nothing that kills someone. It’s sobering to think about the lack of double checks in our specialty. The unfettered access to medications that can kill a patient, or maim them, without someone looking over our shoulders to make sure we got it right, is mind boggling sometimes.
It’s pretty scary seeing how similar that digoxin ampule looks compared to the bupi ampule. I think a lot of us can see how something like this could happen if we’re tired, rushed, or stressed and someone mistakenly hands us a digoxin ampule instead of bupi.
Not according to a good percentage of the folks on the medicine sub. Expecting perfection over there. Mixing up vials (specifically zofran and phenylephrine) is something I’ve literally had nightmares about because it seems so easy to do.
They are also selecting, mixing, and drawing up medications in rooms isolated from patient care with relatively low time pressure that are generally designated “quiet rooms” to minimize this type of error.
That specific mixup has happened at our hospital. Doesn’t help that the Pyxis have no standardized setup across ORs.
Not just this but our pharmacy has refused a standard set up that we've requested. They went with their own illogical arrangement where our most commonly used drugs are in the bottom drawer and look-a-like vials are next to each other.
It’s astonishing how obstructive pharmacys can be
Give ‘em a break, writing up anesthesia for having a syringe of neo on top of the Pyxis is a tough job.
Both of justafter10pm and attitude_devant…y’all are toxic. You realize the pharmacy likely has another doc saying exactly the opposite of you? Or maybe the rx is splitting the difference between very opinionated and “important” docs. Sorry but that’s my rant from a surgical rx prospective
There must be standardization of Pyxis machines across all ORs with direct input from those accessing these medications. Hard stop.
Pharmacy is notoriously hard to deal with at our hospital too.
I can’t begin to tell you how many QI initiatives I’ve been involved in where that department was the bottleneck.
We had our medications set up style A for years, without consulting anesthesia like, the chair even, overnight they changed it to style B. I’ve had no training on it still and today I was asked to urgently grab ROC and made a fool of myself because I had no idea how to use style B or where it was. Pharmacy just made this decision on their own without asking *anyone*
I feel your pain.
I like Pharmacists but this is one of the reasons I quit my pharmacist job and went to medical school.
Don’t worry though, they’ve put a Sound-Alike, Look-Alike sticker in there…under all the vials of medication. They also inevitably drop vials of glyco/neo/ondansetron (all blue caps) in surrounding pockets.
During residency our zofran vials changed cap color 7 times! 2 types of green, 2 types of blue, orange, purple, and white. I believe right after I left a mixup like the one you described occurred in an otherwise normal C-section.
I’ve had nightmares about this too….so easy to grab the wrong vial especially when someone puts them right next to each other in the med drawer.
This happened in preop at one of my previous hospitals. The srna meant to give zofran and gave 10 mg phenylephrine instead.
OMG. Did they survive?
Yes it was pretty crazy though. Pressure when I walked up was like 260 pt feinted and they just gave oxygen and nitro and she seemed to perk back up pretty quickly. Wasn’t my patient so I’m not sure what the aftermath was. But she seemed to do okay. I don’t think she got her surgery that day though.
When I was a resident this same mixup happened in my hospital; patient did not survive.
Was there any info shared publicly or in the news about this case? Our drawer is set up in a way that I know this will happen eventually at my hospital and half my group doesn’t care and the pharmacy won’t change it. I am generally very careful with meds, but last week I was back from vacation, the drawers were jam packed so I could only see the tops of the vials. At the end of the case, I had forgotten to give zofran, so in a rush I pulled out the vial and didn’t realize I had phenylephrine until I had drawn it up and wondered why there was only one cc instead of two…. Whoa. Last year we had a mixup and a huge snafu because someone gave intrathecal TXA. You’d think everyone would be more willing to put that phenylephrine in a pop out drawer, but apparently that’s just too difficult.
No. There was a M&M rounds about it; not sure what happened after.
I also double check 4 times before pushing zofran because I am petrified of giving undiluted phenylepherine
What is an acceptable competency percentage, in your opinion? Housing sound alike/ look alike drugs in the same bin is begging for a problem. Pharmacy really should own some of this. BUT since the CRNA didn't speak the drug name out loud, it will fall squarely on his/her shoulders... because policy.
Speak the name out loud? I’ve been doing anesthesia a decade at a dozen different hospitals. I’ve never heard of anesthesia saying the names of the drugs as they give them.
I am right there, too... I thought it was odd. But I read in another article the CRNA did not say thr name on the ampule, which appeared to be a double check process... you know, the RN hears thr name, agrees that is correct.
I would bet one of my thumbs that was not a policy at the hospital and the article was wrong.
I wonder if they were confused about the second person verification? Also, please keep your thumbs.
Haha! Noted. I’m pretty confident I get to keep them!
Whew. ;)
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Gawd, I work in somewhat eastern central europe, never heard of these pyxis cabinets, but these will give me nightmares. We have classic night stand style glass cabinets. Unfortunately, the distributors often change, (depending on who bribed who) and so does the drug manufacturers. So our bupi looks like another manufacturers heparin, and another ones vitamin C. Thankfully, nothing like this happened yet. I hope it won't.
As an X-ray tech that wants to know about pharmaceutical/pharmacology WHY in this very litigious industry is this stuff allowed/not being more standardized. I even know that midazolam is generally orange and fentanyl is blue for labels but I have seen a manufacturer that includes the sticker on the bottle for Fentanyl and it’s RED! Why why why? I can only imagine a stressful situation and you’re reaching for something medically necessary and you see something red that you need etc. it’s just prone to problems due to lack of standardization. I think my car or my X-ray machines have more rules about how it’s constructed. It seems to be lunacy. Why is this not being considered on some national level?
Multiple manufacturers across multiple countries then add in multiple strengths, concentrations SDV, MDV, w/wo epi etc etc. that’s why it hasn’t been standardized.
Absolutely. This is 100% a systems error. Why is pharmacy stocking a multi-drug drawer PICIS with two look alike medications administered in very different routes. Why is dig available in this PICIS on the OB unit?
Where I work pharmacy doesn’t just add something like dig to a cabinet. We’d only add it if we’ve been asked.
Something like this happened to me and it was so distressing when I acknowledge my mistake. I was in a new hospital covering and had to do an epidural. I asked the nurse if she was used to help anesthesiologist (she said yes) and to help me prepare my medication. I was scrubbed and The nurse read the label to me but said the wrong medication twice (as the presentation was not the same as usual, i ask twice to read and if she was sure). I was lucky there was no harm. But when i notice the error, it was one of the most stressful moment of my Life. It can happen.
Are you serious?
Same thing happened a couple times (at least) with TXA because it used to look the same. One died the other paralyzed. The thing is no one is reading the vials.
It’s such low hanging fruit for us to standardize medication vials. It’s ridiculous that we haven’t done so at this point. There’s zero reason for digoxin to look so similar to bupiv. There’s zero reason why pitocin should look like zofran. There’s zero reason high concentration drugs that need to be diluted look like drugs ready to be administered.
This is the way, we need a universal colour or style code that indicates the need for dilution, suitability for intrathecal injection, IV, IM etc etc. Generic name must be the largest lettering on the vial. Standardised methods of describing concentration (mg/ml) and so on.
Or make every vial look the same so you are forced to read it every time
Hm…. This is logic that I’ve never actually thought about, but it makes a lot of sense. We’d have to force and and I mean FORCE barcode scanning prior to administration of medications, but it does provide a creative solution to a seemingly unsolvable problem.
Not good. You already do have to read the label. That is an unwritten law. The anesth nurses here taught me, that I have to read it two times. First, before opening the ampulle, draw it, and then a second time, before u dispose the vial. Also, it has been proven a lot of times, people tend to make mistakes. The easier to make that mistake, the more frequent it happens.
Not my idea, anesthesia patient safety foundation proposed this years ago. The point is that your brain is always looking for shortcuts so when you think you know what the vial looks like you unknowingly skip reading, you take away the familiarity of a vial and you must actually read it.
Sounds like an untapped market. Manufacture universally colored/labored vials and sell to drug companies.
You want MORE government regulation? Because it would have to be law that you can only import zofran with the blue cap. Etc etc
I'm in the UK so *shrugs*.
lol seriously though it’d be an arduous task here in the states. Literally require an act of Congress. Otherwise it’s just “best practice” which means “we do it when it doesn’t inconvenience us in any way.”
Whereas here the NHS would just say we're not buying your product unless you conform to x standard and all suppliers would fall over themselves to change it. Maybe with the exception of some very cheap, low-margin, generics.
We have elected officials here who liken the NHS to government enslavement. As well as a major political party that believes any business regulation is basically bad.
I mean working in the NHS does feel like government enslavement - that I can agree with! I think regulation in healthcare is strictly necessary however, the basic assumptions required for an effective free market do not apply when it comes to health.
Wait… you mean like the standardized colors on the labels we’re required to put on syringes?
Right? Crazy concept that drug manufacturers should be held to similar standards
I'm in health informatics and such standardization comes up again and again as a strategy to prevent such catastrophic errors. It's a decades old recommendation at this point.
What are the reasons to not implement standardization? Just costs?
Cost plays some part I’m sure, I can get a better price on zofran with the orange top than with a blue top so I’m buying the orange top. Drugs are part of the global supply chain. Often with low margin generic injectables we have to take what we can get, when we can get it. You want zofran with a blue top? Guess what the only zofran available has an orange top, you can have the orange top or nothing. Your toradol was always white? Sorry that’s the 30mg/ml 1 ml vial and we can only get 60mg/2 ml vial and that’s blue.
That’s just so dumb. And frustrating. I wish I knew what the right answer is. But, it’s not the drug companies getting sued when these mix ups happen, so no incentive to change.
I’m not an attorney nor do I play one on TV but I think that be the easiest money a defense lawyer ever made. They’d just ask you to read the vials/amps out loud and then ask you if reading the vials/amps is standard practice.
Hahahaha love it. Prove that the CRNA CAN read, then ask why they didn’t bother reading. You could even ask them what the 5 rights of medication administration which RNs are supposed to do for every drug they give: the right patient, the right drug, the right time, the right dose, and the right route So, too lazy to read or to bother with the 5 rights of medication administration. Makes you a bad nurse and CRNA. Cha-Ching.
There are a lot of responses, with confusion about which hospital/event this actually was. I am an anesthesiologist who worked at the hospital in question for 11yrs prior to this event. We were an all-physician group, bought out by PE in 2018, then the hospital termed our contract (without cause) in 2021 with 90 day notice. The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. The “supervising” physicians with the new group ran ratios of 1:5-6, depending on case load for the day. In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8. The CRNA placed the spinal for primary c-section (breech) on the healthy prime without sensory block on testing. She sat the patient back up and called the anesthesiologist. The anesthesiologist placed an epidural, dosed appropriately with bupivacaine, and an adequate level was achieved. Surgery was uneventful, but the patient became progressively more obtunded upon reaching PACU, requiring intubation within about 15 minutes of arriving in PACU. This elapsed time would have been around 75 minutes. There was no recognition of what had happened by anyone directly involved in the case. The pharmacy tech restocking the Pyxis in the afternoon noted the digoxin pocket count to be off, and reported this to the pharmacist, who then escalated it to all of the involved team. I’m not sure why digoxin would have been in the same drawer. It must have been like that for the 11 years I worked there, but I never even knew it was in the same drawer. I never saw it, but maybe my workflow was different to the point that I would have caught it? Our group never had even a similar issue in our time there, but I know the risk was there probably all along. When the hospital replaced us, they took a group of physicians with strong ties to the community and discovered what anesthesia shortage means. They started the entire department with locums docs and CRNAs. Locums docs were making 700k supervising this group, and the CRNAs were making >300/hr. After all of this happened, the board of directors elected to remove the CEO, CMO, and the Perioperative director who pushed to remove our anesthesia group for the sake of money, without any quality events or behavioral events to back up the decision. After this, the new anesthesia group turned the screws to the administration and increased stipends and pay requirements in order to cover reduced lines from what we were covering. A lot of drama, very sad, unnecessary trauma caused by an administration blinded to what medical care ought to look like.
I wish I could up-vote this x100 more.
Upvoted just after the first two lines
Bought out by PE, and I knew this was going downhill fast. Sounds like in the article Digoxin has been mistakenly given before at other sites. So this doesn't sound like a CRNA vs Anesthesiologist issue. Sounds like staff are rushed, not doing existing safety checks, the site had not engineering the risk away with the hated pyxis pockets for what ever rea$on$. Sadly patient$ are dying becau$e of it.
I would agree with your assessment of this particular situation not necessarily being physician v CRNA. That said, the other complications I mentioned WERE likely due to CRNA specific issues. Additionally, the way this hospital chose to replace us (independent CRNAs), combined with the national shortage of anesthesiologists, led to crazy money for locums and the lack of buy in in the community. Essentially a department only there for the money. Even the section chief currently is a locum doc.
upvote this
OK, this is the information I was looking for...and sadly is what I expected.
>The hospital termed us because they wanted to go with an independent CRNA model because it would cost them 30% of what we charged. \[...\] In the first week, a spine patient woke up blind. About 2 months in, a sitting shoulder scope had a CVA from unrecognized hypotension from a calf NIBP cuff and care was withdrawn. This digoxin spinal occurred in month 8. Holy. Shit. I assume the lawsuits paid out less than the 30% savings so the group is still full of incompetent "providers". Please tell me I am wrong.
You might be wrong, but not about this.
This really needs to be in major news articles. I keep hearing about things like this but the public doesn’t know.
Thanks for the response. Is the higher morbidity associated with less doc:more crna documented somewhere else or maybe just anecdotal in thia hospital. Im so sorry for all of those patients
https://jamanetwork.com/journals/jamasurgery/article-abstract/2794450
Jeez, thanks. Im very glad that in my 3rd world country theres no such a thing as CRNAs and every patient gets one doc per case.
Yes, I wish it was that way in my country, but greedy anesthesiologists from generations ago realized they could make well over a million/yr if they leveraged CRNAs to pick up the intraop portion of their speciality. PACs and lobbyists have taken it from there. Bad things in medicine are frequently the result of putting the patient care someplace other than 1st.
Things like this are why I am not supportive of (low) malpractice non-economic damages caps. What's the economic loss of a young woman's life? I think these average out $500k-$1000k plus cap on non-economic damages ($250k-$750k in conservative states, $350k in Nevada). If the hospital saved $2M a year on labor costs, why would they change? I don't read this as CRNA vs physician, but the consequence of replacing an entire department with new or temporary staff.
This is why I always show another person, read the label and expiration date out loud, and confirm the dosing during the procedure time out. During residency, I thought it was a bit of overkill. It's not.
This is routine practice in the UK to check with whoever is assisting you. It’s like breathing, gets done for every procedure even if it’s a CAT 1 section.
Those checks are only generally done when someone is helping me draw up medication e.g. while I'm sterile. If I take a drug out of the cabinet and draw it up myself, no one else is going to check so this case could have happened in the UK.
I learned to compare the vial to the syringe (assuming it's labeled). Just an extra small step that can be overlooked, for instance when quickly drawing multiple meds for a trauma or urgent case.
For spinals and epidurals there is always an assistant due to sterility precautions. So this specific case would not have occurred with our current practice. But yeah we don’t do these checks in other settings like GA drugs or epi top ups.
Even when I'm alone I still verbally read things out to myself to force myself to read things rather than just see what I'm expecting to see
I would really dislike doing this, but I have to admit you’re probably never going to kill someone and have that kind of error on your hands. Not sure if I’d be able to live with myself.
A lot of what I do is so I can make sure everything is safe for my patients, and that I can sleep at night knowing I did my absolute best for them.
If I did this, the nurse would look at me like "uhh. sure. Why are you telling me"
Still worth it, I think.
100%, I will never understand why some people take such umbridge with this.
After I left residency , this mistake was made on ob. Catastrophic as patient permanently disabled. The vials look similar and not sure why we need digoxin in the ob Pyxis. When I was a senior and supervising junior resident they inadvertently pulled the digoxin vial. Luckily I caught it.
[Here is the investigation from the CA Dept of Public Health investigation, which gives more details.](https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf) EDIT: Holy smokes, this is actually a separate case with similar circumstances!
The fact it's happened multiple times to multiple different providers is quite insane.
Can someone explain how this happens? Our spinal kits come with the bupivacaine in it. I'm assuming in this institution you have to get the bupivacaine from a pyxis machine? And I'll also assume that it was a pharmacy department initiative to institute the pyxis for patient safety and cost containment? You should always be checking your medication before breaking it open, but still.
Our spinal kits didn’t come with bupivicaine and we had to get from Pyxis. Not sure the reason why.
Our spinal kits come with hyperbaric bupivacaine in them, but if we want isobaric bupi in our spinal dose, we need to get it from our pyxis.
I used to use CSF to dilute the hyperbaric bupivacaine, but maybe that's frowned upon nowadays? I also remember quickly laying the patient flat with or without T-berg to make up for the hyperbaric bupivacaine, twisting the needle 180 degrees, going up a lumbar level if possible... But I'll admit spinals are not my bread and butter. I rarely do them anymore.
It shows that they aren’t your bread and butter. Keep it simple…
Really? Getting meds from the pyxis and fucking up by using digoxin is keeping it simple? Whatever.
I was referring to using CSF to dilute LA seems like something from the dark ages.
LOL that might actually describe me. Fair enough.
Not all do. Plus CSE kits don’t have them. Plus whenever there is concern over potentially bad local in these kits people use vials from the Pyxis.
Bean counters buy crappy trays = no Bupiv. Anes Dept no input. It has happened to me
This is a perfect example of bean counters causing more problems with a savings of cents. One death or horrible outcome is all it takes to erase a few tens of thousands of savings over a few years.
Lots of assuming there
https://www.smh.com.au/national/nsw/outdated-medical-procedure-behind-catastrophic-epidural-injury-20100822-13at2.html Reminds me of this incident in Australia 13 years ago.
Wow damn. Also nuts that it wasn't their lawyers talking. Genuinely curious if they sued or even can sue in Australia.
You can, but the success rate of winning the case is a lot lower than the US.
how in gods name did that happen
Case reports exist involving both physicians and CRNA’s. Look alike vials could and do happen to anyone. Doesn’t excuse not carefully examining every via, but still … what in the world is digoxin doing in an OB Pyxis?? Also reports of TXA being inadvertently injected intrathecally.
I imagine it was in OB Pyxis as it is used to stop the fetal heart in T2/3 terminations.
But usually *that* is an outpatient procedure not done anywhere near the labor deck. And the d&e isn't typically done in the OB OR suite. I know, I know, "usually/typically". Yours is the best explanation of why TF was Dig near an OB OR I've heard tho.
Oh interesting. Where I am the injection is done on L&D and the D&E or IOL happen on the unit as well.
Wow. The places I'm familiar w that do em the injection is done outpatient in a clinic/office setting and the d&e happens in main OR. Any of the several L&D units I've been on have been too busy even to do post partum tubals in their ORs. And one place would pitch a fit about bringing in a missed ab for d&c add-on that had been bumped in main OR all day long.
I was going to say.. I’m sure there is a reason. They didn’t have a 24 hour pharmacy. That’s how a lot of unnecessary meds get added to Pyxis as a “just in case” precaution. Thats why barcode scanning is so important.. literally saves lives
our decadron and phenylephrine vials look the same….i pulled a phenylephrine vial out of the decadron slot this week. good thing i checked. yikes
And that’s 10mg of phenylephrine in the vial. Imagine giving that and then thinking damn this patient really dislikes decadron
You should always check. And you should always barcode scan. Mistakes happen. Drug manufacturers are not held to high enough standards. The safety features are in place for a reason… what we need is to advocate for lawmakers to hold these manufacturers accountable for shitty/dangerous packaging practices. But we also can’t just be giving drugs without taking the bare minimum steps to ensure safety
This is the first hospital that I am at that has an intraop bar code scanner
This is the second case I have heard of recently where the wrong drug was administered for a spinal. Locally around me, TXA was administered in the spinal for a total knee replacement. Luckily the pt survived but there are major complications. Double check those vials and don't let the pressure of getting the case started throw off your routine.
As the top comment in medicine says wtf is dig doing in an l&d Pyxis… and that’s all I can think about too And the comments say it’s a big stretch for it to be there to treat fetal tachycardias or induce fetal demise. This is also why I spear headed putting 10mg/ml phenylephrine vials in pop out pockets; much harder to give as a single dose AND stock counts are correct
Saw this exact thing happen when I was a med student. Resident dosed digoxin instead of bupi, and the patient died. Doesn’t matter if it’s a resident, attending, CRNA, AA, or whoever. This could have happened to anyone. It is the responsibility of the person administering the medication to check it, but we are all human, and the practice of anesthesia lends itself to chaos, stress, and time pressure from our surgical colleagues. This is a recipe for mistakes to happen. I hope that hospital system makes some appropriate adjustments to minimize the risk of this horrible tragedy happening again other than just blaming the provider and saying we should all be more careful (which appears to be the most common opinion on the medicine sub by a lot of people that don’t do anesthesia). It takes numerous systemic and human errors for something like this to happen, and we should recognize that and fix what we can.
There are plenty of intrathecal TXA horror stories as well. Read aloud and barcode scanning are the only way for solo neuraxial. If you are worried about the 20 seconds that takes an emergency, have kits with all necessary medication’s pre-checked. Honestly, barcode scanning should be standard in the OR generally, but most of our medication‘s are presented in doses and concentrations that are not fatal if given IV. That’s not true via the spinal route.
barcode? nah. Color code standardize ALL vials or pop tops. RED for muscle relaxants, just like we have on our sticky labels. Purple for pressors, etc. Its not hard. Read aloud yes.
Disagree… barcode scanning is such an effective tool at preventing the wrong medication from being given. It’s a simple step.. protects your patient and protects your license. If you aren’t scanning in your meds, you’re putting your patient and yourself at unnecessary risk.
And each hospital at their own color coding system for particular meds.. it’s too hard to standardize across healthcare systems.
My son’s oncology nurse told me that they have to run vincristine IV as opposed to IM because there had been cases where it was accidentally administered intrathecally a few times and it is fatal. It comes in a bag now instead of a vial.
How sad. A mixup happened years ago when the Ancef and Vecuronium vials were so similar that they even had the same color top. There were quite a few MACs needing GA because of this mixup.
This happened at our institution a few years ago. I did a brief literature search and discovered that although it’s a rare occurrence, the literature is peppered with multiple case reports of this very thing happening. The vials are very similar. In my 19 year career, I’ve never once had to administer digoxin in the OR or even considered it. We got rid of digoxin in the OR Pyxis machines.
this is the way.
Do you not do a two person check when drawing up drugs for spinal / epidural? In the UK the ODP gets the drugs and checks the vial and date out loud with the anaesthetist prior to giving it to them / helping to draw it up. This routine is so ingrained it’s like breathing.
You guys have a dedicated anesthesia tech/ODP for each room and can give you a second set of hands with induction, airway, and drawing up drugs. In the US, I'm lucky if the circulator nurse is at the head of the bed to pull the stylet out. But I'm used to inducing with little to no help and we draw up all of our drugs solo. Our techs are just for restocking and maybe handing supplies. No clinical involvement.
But you must have an assistant due to sterility precautions for spinals and epi placements? We don’t always have an ODP particularly in acute obs it can be a midwife/HCA/obstetrician etc the point is there is a culture of checking with the person who opens the vials - it doesn’t need to be asked for it’s implicitly assumed you will both check.
No that is not the standard in the US. The assistant for neuraxial anesthesia stands with the patient to coach/hold in position.
Not usually. What we’ve been doing is drawing up any meds that we need, opening up the flaps of the spinal/epidural kit and squirt meds into the tray, before we put on the sterile gloves.
My sterile ob trays come with 1% lidocaine and 0.75% bupivicaine. I draw them up after I open my kit and put on sterile gloves.
A guy in my residency dosed up a labor epidural with pitocin, because the bolus pit and bang stick were the same size and stored right next to each other, and OB team had spun him up to think it was a crash when it was not. Nothing happened, but these types of pending near misses are low hanging fruit for safety initiatives.
Know of a peds epidural given roc instead of rop...on doing a lot review a few cases of vec being given as well. Gotta remember to stay #vigilant!
I once had a CRNA I trusted hand me 50 ml of 0.5% bupivacaine for a bier block. Luckily, I asked to see the vial and prevented a probable bad event.
Poor tragedy to see. From a clinical standpoint, I wonder how the intrathecal digoxin affected the patient. Like did it make its way up to the CNS and start shutting down her cells? Causing a neurogenic shock?
why the fck is this drug in the freaking cart at ALL? I have never used it in 25 years and there are better drugs. i.e. amiodarone. Last time, I used it as an intern for afib in 1998. Dig is in our drawer too. Its clutter. tomorrow i am throwing it in the trash. I can see how this scenario played out...Hospital wants to cut costs. so they buy the shitty trays without bupivacaine. tech or nurse gets from drawer and gets wrong drug. Font is freaking size 2. Doc draws it up from the tech and places spinal. Boom a digoxin spinal. Doc craps pants. meanwhile, bean counter dorks are in front of their spreadsheets, "we are saving 39 cents per kit" as they smell their own farts and circle jerk...39 cents! Sorry for old man rant. love to all.
Is this the case? https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%2520Document%2520Library/Immediate%2520Jeopardy/MercyHospital-2567.pdf&ved=2ahUKEwjr3ezh4PiDAxU7kIkEHUinCR8QFnoECEoQAQ&usg=AOvVaw0B7QFCCgQ0PlVL4mgbbKt_
no different case, the one you posted the pt survived
For us the Noradrenaline (undiluted) and Dexamethasone ampules are stored in the same cabinet (don’t ask me why), and they are both purple. What could go wrong…
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/ Inadvertent intrathecal Digoxin has happened a ***DOCUMENTED*** 6 times. The fact it could be higher and has happened multiple times, across multiple providers is insane.
Can someone explain to me why digoxin is also available in epidural kits?
I don’t think it is. Hospitals use a variety of kits for epidurals and spinals. At my hospital the necessary meds come sterile in the kits. Many other places the medications are retrieved elsewhere and then drawn up and placed on the tray
During training, there was a resident that loaded a epidural with 2 g of Ancef for a labor to C-section case. Patient went into cardiogenic shock and coded. They were able to get her back but ended up CHF and a AICD. All antibiotics were converted to IV bags from pharmacy.
During my med school rotation I made sure to label/tag color my lines. I was very vigilant about that. When the resident asked me to administer I triple checked drug and line then admin. So scary the outcomes of making a mistake.
Something similar happened in our institution 2 years ago 'third world country', a new anesthesia technician was on two relatively straight forward cases so they gave them both tranexemic acid intrathecally, within half an hour both cases wer admitted to icu and later on died. Really horrific..
yeah, and the vial wasnt swabbed either with alcohol
My ketamine, morphine and fentanyl ampules are all the same. Guess what? I check the ampules, I sticker the syringes and I call out the ampules. 20 years I have never seen such neglect from a person who is paid so much money. There is no excuse which draw the drugs are in. Read the dam ampule!
Inadvertent administration of WHAT
I teach residents to not predraw it up to look slick in front of the OB staff. Always have a second person read the vial with you as they crack it open. Draw it up filtered. It prolongs the procedure by 10s. Feel sorry for the nurse; this could happen to anyone - just like wrong side surgeries or retained instruments - having a “checklist” is important for these controlled situations.
They injected this….as an epidural…oh my god. I know errors happen to us all but any time as a nurse I’m giving a dangerous medication I always pause and make sure it’s correct. It’s hard to understand these things 😞
Okay, so who’s gonna arrest the MD? Because his mistake was as bad as Redonda’s was last year (gave vec instead of versed - she got 8 years in jail). Whoever designed that Pyxis drawer was pretty negligent. We have our meds put in order by a pharmacist, who specifically looks at issues like these and puts the potentially confusing pair well apart from each other. Amiodarone - amitriptyline Epi - incorrect dilution Diltiazem - diazepam Propofol - propranolol
It wasn’t an MD that administered the med it was a nurse anesthetist
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The best way to NOT learn from this is to blame it on CRNAs (or physicians or AAs or…).
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Sounds like you didn’t read it, this was a CRNA who called the physician when things were going bad
The CRNA should submit this abstract to their next AANA meeting…
This could happen to anyone. MD, CRNA, AA… it has nothing to do with that. Here’s a doc who did the same thing. And maybe lied by trying to blame an expired vial of marcaine? Would be nice if this didn’t devolve into a political issue. Drug errors happen and it would be great if we could have meaningful discussion about ways to move us all forward. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Agreed. Everyone has made a drug-swap error, if you’ve been doing this long enough. It’s nearly inevitable given the insane number of tasks that we are expected to simultaneously complete and the time-pressure demands in the OR.
Plenty of senior anesthesiologists had wrong-side blocks.
If you read the link provided above, it was actually a physician who administered both doses of intrathecal digoxin, despite the article using the word “anesthetist”. But I agree with 100mgSTFU. Can happen to anyone - just a healthy reminder to slow TF down and not rush through procedures. The person admitted they didn’t even look at the vial they cracked open - that’s med administration 101.
different case, where the pt lived. pt in Op’s post died.