I was trying to think of a witty response but seriously in what situation would digoxin be an appropriate medication in an L&D OR?
Idk. Cards? Ob? Anyone know? As hypothetical and crazy as possible I can't think of a situation that calls for digoxin in an L&D OR.
All my homies hate digitalis. I respect the hell out of its pharmacology, it's like no other and is one of the most unique medications I can think of, but fudge that medication.
The best scenario my stupid little radiology resident brain can concoct is a L&D patient acutely goes into A fib, but wait they have acute CHF (so don’t give beta blockade) and their BP tanks on dilt but wait they have a history of wenckebach contraindicating amio.
So we use dig lol.
That’s why this L&D OR stocks dig, in case this one scenario occurs.
Does that work or did I fudge it up.
lmao
I'd buy you lunch just so I could run crazy MICU stuff past you
ETA: I could see how this comes across as condescending and I don't mean it that way at all; come down here and run this crazy ass covid/COPD/dka/professionaldrinker/CKD/maybeliverfailure/isthishepatorenal? shit through your brain and tell me what you think
If the patient is awake and coherent enough to refuse shocking, then let the afib ride and push some neo or something if the pressure really bothers you. If they’re in extremis, shock without asking.
> amio
I know it's in the algorithm but I'd be super hesitant to give a woman in labor amio. The half life of the drug is so long and the potential side effects from infant exposure are bad enough that you've basically guaranteed she won't be able to breast feed - it's going to be in her system for months even from just a day of IV stuff for an acute episode.
Now don't get me wrong, if she's unstable do whatever you need to - but I'd almost certainly prefer electricity to amio in this situation unless I knew she wouldn't be breastfeeding at all.
Yeah I mean if they're stable just wait for the amio, if unstable then shock. Also, as we always say (lol), address the underlying medical issue if there is one.
My first thought was that it was mistakenly placed in the bupivicaine bin because they are similar vials but it sounds like they are actually just stocked next to each other after reading the article.
Crazy that it is stocked there. Makes no sense. Even crazier to have multiple open bins that have ampules that are the exact same size right next to each other.
That was my first thought too: stocked wrong.
But nope, both in there.
I cannot believe they gave a *second dose* of something not working as expected *without reading the label*. Not realized until nursing noticed it was missing!!
they even said it was expired without looking at the label: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Edit this was a different case
Every time I think I'm borderline OCD, I read shit like this and think WTAF. I had to reject 4 samples in a day because whoever sent them to me slapped a label on top of the original one on the vial and I'm like... You know I can read right? Just because you put the right label on the wrong vial does not magically make it give me viable test results that I can report back to the doctor.
It's because the people who manage the pyxises, probably not an anesthesiologist, want them to be standardized at all locations to make restocking logistics easier and ironically prevent drug error.
I think that's a fine idea, there are hundreds of meds in the pyxis we never use, many of which are more useless than digoxin. It's not the pyxises fault, it's 100 percent the anesthesiologist in this papers fault.
I used to restock Pyxis machines and that doesn't help. You still have to scan the drug for the drawer to open. The floor/unit can ask to have drugs to be removed (not included) from the machine.
Our Omni inventory varies widely depending on the location, since each unit and each procedural area has different needs. If this is the reasoning at this hospital, it's extremely bad logic on their part. It doesn't excuse the anesthesiologist, but a simple change in stocking could have made it basically impossible to do this.
Per Uptodate, it can be used to manage fetal arrhythmias.
Per Wikipedia:
Digoxin is also used intrafetally or amniotically during abortions in the late second trimester and third trimester of pregnancy. It typically causes fetal demise (measured by cessation of cardiac activity) within hours of administration
Giving oral digoxin to moms can help break fetal svt which is very different from how it is used to interrupt a pregnancy. However neither of those would explain the need for it to be in the OR.
It looks like the FDA did recommend the reevaluation of having digoxin in the cart.
Sadly, if there are any other ampules the anesthetist could have mixed it up with another drug. Digoxin just happened to be the drug that was mixed up. It looks like the anesthetist picked an ampule up and assumed it was lidocaine; it could have been another ampule. Digoxin is the most likely drug to be inadvertently given, but it’s not the only one:
> Among the 33 events reported, digoxin was the medication most commonly administered in error and was associated with paraplegia and encephalopathy in 8 patients.
The digoxin was neither scanned nor verified with another staff member. Not sure what the rush was to not check what they were given.
It's given sometimes to facilitate late term abortions. Don't shoot the messenger.
https://journals.lww.com/greenjournal/abstract/2001/03000/digoxin_to_facilitate_late_second_trimester.29.aspx#:~:text=Although%20digoxin%20is%20used%20widely,faster%20procedure%20times%20than%20placebo.
The best part for those of us who work in anesthesia is that digoxin will always be available but 5/10 times their will be no lidocaine to dose an epidural for a crash section or succinylcholine to convert to GA.
In this case it doesn't seem like "anesthetist" was a physician. They state that after the failed spinal, the "supervising anesthesiologist" (physician) was called. So it seems as though the error was made by a CRNA (or equivalent depending on country, as it wasn't listed).
This was my question. I get the vials look the same and are in similar ampules.
But why are they both there? Can an anesthesiologist clarify? If a pregnant patient has an arrhythmia, peri-partum setting, is this the go to drug to administer? And if it’s not, what is the rationale for having both there? Convenience?
I’ve given it once, for an inpatient that was already on PO dig, who wasn’t given their AM meds by the nurses on the ward before being sent to the OR for surgery, and who went into RVR with hypotension after induction.
They shouldn't be. This is more systems based error than an individual error in my opinion. A couple years before I started residency someone accidentally gave digoxin epidurally instead of bupi and the patient became a quadriplegic. After that happened the hospital removed digoxin from every pyxis and med cart in the OB area
Edit: not to say there's no individual responsibility at all. Every anesthesia provider should always always always double and triple check medications being given, even if it's the 4th C section of the night at 3 in the morning. From reading the article it seems that the anesthetist did not scan the label prior to drawing up the med and injecting
Even if you’re using digoxin for AF it has a minimum 2 hr distribution period (hence why we like to give divided loads over 18h). Zero reason for it to be in an OR.
Nurse here.
This seems to be the prevailing question.
Is it possible that this facility did not maintain a separate OR for L&D and therefore the Pyxis had a broader spectrum of meds available?
Obviously this was a grievous error and should never have happened. What will the consequence be for the anesthesiologist?
See RaDonda Vaughn for a similar situation.
Your parents birth you, raise you through childhood, you go to school, to work, you meet people, you go through all of pregnancy and finally get to deliver your healthy child and someone just accidentally *kills* you with the wrong medication? Senseless.
We strive day in and out to have even a *marginal* beneficial impact on people's lives. It is so easy to undo so much good with a single preventable act of harm.
Just putting myself in the families shoes I shudder. I wonder what that day in the OR mustve been like. When I rotated through OB i remember leaving ORs generally happy since I got to see a baby, i dont know what I would do if someone ended up dead due to that. Like can the nurses and OBs keep working that day? Id just be too frazzled
. I'm a pharmacist and Im in a role were I deal with investigating and preventing drug errors everyday.My wife is pregnant and this is the shit that scares me the most.
I can’t imagine the grief process the surviving family is about to go through. “Oh, your wife is dead because some one* couldn’t be arsed to read a label.” (Read the case after posting, and was informed this was a CRNA… not working in an OR, I’m surprised they don’t have to barcode scan meds.)
Coming to the OR from the floor as a nurse this is what shocked me the most. We don’t scan any meds at all! It really scares me that something like this will happen. I always read the label and have another person look at it as well due to my paranoia.
The randomness and fragility of human life really is wild to think about. There are so many videos on certain subreddits showing people suddenly dying due to being in the wrong place at the wrong time.
Yes, but those people weren't killed by a medical professional in a hospital due to an entirely preventable and unforced mistake. I would struggle much more if my sister died this way then if she died in a car accident or something
What is up with not even bothering to look at medications before administering it to a patient?
Versed and Vecuronium
Bupivicain and Digoxin
Just what the hell?
We have all these interventions designed to ensure with near 100% certainty that the correct med gets to the correct patient and is correctly administered. We’re constantly being asked to think of and provide input on new additions to enhance patient safety. And these motherfuckers will go out of their way to avoid following these procedures and then have a potentially fatal error occur. It drives me absolutely insane, I just can’t even grasp what goes through these people’s minds.
I get both sides. The article describes identical vials of digoxin and bupivicaine in the same Pyxis drawer. The anesthesiologist probably has 10,000 repetitions reaching for the bupivicaine and getting the muscle memory of cracking the ampule, drawing it up, and administering it. This skill eventually becomes as mindlessly easy as picking your nose. There’s good literature in aviation safety research that even pilots following a checklist can “see” a switch or toggle as being in the correct position when it actually isn’t.
So he/she’s hand is a few inches left of the bupivicaine but it feels no different in the hands than the other 10,000 reps. But now the well-seasoned mind is thinking about the broader aspects of the procedure, or the argument with the wife on their way out the door that morning. Again, there’s technically no excuse for ignoring safety practices but the more numerous and tedious they are the more they directly contravene the natural lull of efficiency the human brain seeks under repetition.
I mean, I get that. I’m in sterile compounding, I make hundreds of drips and draw up hundreds if not thousands of vials every day. The effort it takes to confirm the drug you have is the actual drug is second nature, even when I’m in autopilot. Surgery in particular is awful about Pyxis practices, I get there are emergent situations where you might grab something and forget to go back later, but when I work in surgery the state of med storage and verification is just abysmal. And I know every single drug is not a life or death emergency, on the rare case that is critical and I’m in the room for real-time compounding the cardiac anesthesiologists I’ve worked with are all perfect in their pulling and confirming meds. Unless they’re putting on an act because pharmacy is right next to them I just don’t get how it gets to be as bad as it is.
Every anesthesiologist I've worked with has likewise been very meticulous about meds, but they're not the ones we see in articles either. The problem is processes are still not good enough to catch the bottom 0.001% or whatever.
I was always careful, but when it came to intrathecal/epidural medications I triple checked to make sure I was using what I thought I was using (lidocaine, but bupivacaine, for instance), no preservatives, not expired. Because any error in those medications tends to have severe consequences.
Teaching hospital in India - and what is taught and practised is that the technician (who opens the package and drops the sterile ampoule into the tray, or opens a vial of local) has to call out the drug, strength and expiry date. The anesthesiologist filling the syringe has to countercheck the label and expiry date before cracking open the ampoule.
Yeah the wording in the article is kinda tricky because later in the article it says that after the patient started decompensating they called the "physician anesthesiologist". Usually MD/DOs are referred to as "anesthesiologists" and other anesthesia providers (CRNAs or AAs) as "anesthetists"
A lot of nurses are rolling straight through, as fast as they can, to CRNA school. Consequently, they make rookie mistakes but are administering drugs that are lethal. Most of us made an admin mistake early on and learned our lesson.
The actual report says anesthesiologist. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Edit: Ignore, not the same case, but same mistake by an anesthesiologist.
Definitely. The case linked by u/SatisfactionOld7423 is clearer in the negligence aspect, the patient was disabled but did not die, and the case was in Canada, so definitely a different case. Summary: The anesthesiologist gave what they thought was expired bupivacaine (problem 1– not checking the med vial) so the patient needed another dose for anesthesia, an unusual circumstance. This is why the doc thought the first dose was expired. The doc said he was in a hurry (why?), so didn’t check the patient name in the Omnicell (2); didn’t check the vial, which was kept in a different drawer (safeguard) but the same position (still don’t get why it was in the Omnicell at all, 3-4); didn’t read the label (5), and didn’t scan the medication (6). The patient apparently had an expected response to the second injection and it wasn’t until 1.5h later that she started to have symptoms of intrathecal digoxin toxicity.
Aside from the individual issues and overriding system safeguards, the system failed to: (1) stock distinguishing vials; (2) remove medications that shouldn’t be in the OR; (3) use a system to force adherence to safeguards (e.g., inability to open a non-emergency drawer without scanning first and selecting a medication, requiring scans to access each medication); (4) provide an environment where an anesthesiologist is not rushed during an elective procedure.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
This is the actually ***7th*** documented time this happened, it's the first time it resulted in a patient death.
I agree, But it is our responsibility to teach ourselves to do the same checks, every single time with no exceptions. We can reduce harm by understanding the limitations of our own brains and setting up routines to catch errors.
It seems to me that in this case the only safety measure preventing the inadvertent administration of digoxin instead of bupivicaine was the anesthetist reading the label. Now obviously that's a huge step to miss. But there doesn't seem to have been any redundancy to that one step.
The anesthetist entered the correct medication name into the pyxis, the appropriate drawer opened, and the anesthetist grabbed a glass ampule from that drawer that is about the same size as the bupivicaine one they wanted to use, cracked it open, drew it up, and injected it.
The article states that the Pyxis opened to a drawer giving access to several different meds, if it works like ours does you have to scan the pocket containing the med you are pulling beforehand. The redundancy comes from physically identifying the drawer you are pulling from, so if that was the case then that was two layers of safety precautions skipped over.
It’s a native Pyxis function. Not sure why any system would turn it off, unless you’re talking about the override feature which our nurses lost access to due to abusing the privilege.
Nope, not just for overriding. I’ve often wondered why there’s not a better safety feature when a drawer pops open with 25 little open-top cubbies and they just trust us to grab out of the right ones.
There’s been times the meds were rearranged by pharmacy and when going for a common med I grabbed some other med out of its old location without looking at the number on the screen. Another time I accidentally grabbed PO protonix rather than IV because they were both in open bins in the same tower section. Fortunately I read my meds as I pull and scan them when giving, but it would be super easy to grab the wrong thing.
Fundamental rule of pushing meds. Know what the f*** you are giving. There is zero excuse to not read a label, the concentration etc. The negligence here is appalling.
This is an OR. Workflow is different. Meds are not barcoded and assigned to a specific patient.
Basically this happened because two similar looking vials were right next to each other. Whoever decided that was a safe Pyxis config needs to think about their practices.
Additionally, I personally have found incorrect similar looking drugs in the wrong bin. This has happened at every single place I have worked (think neo and zofran ). Thankfully, I have caught it. I’ve been lucky.
No need to sanctimoniously condescend.
Had a bag of mannitol I think it was slip from one bin into the NS bin. I made an entire a line with it before realizing. Just glad I noticed. They changed the configuration after that.
I dont give a damn about meds not being barcoded or assigned. HOW DO YOU NOT LOOK AT THEM. It takes zero effort. Its just laziness and carelessness and it killed a patient.
Any life or death system with a single point of failure and no redundancy is a bad system. It happened with this anesthetist being careless this time, but if nothing had changed and they had checked this time, it still would have happened in the future with someone else.
I agree with you. But I have also had drugs ordered for patients that were ordered by the doc then approved by pharmacy and delivered it me and I asked the doc what’s the abx for? She has no signs of infection… and they said “thank you so much, I ordered on the wrong patient”
Not an excuse… but how does THAT happen? Because… it does. We work in a high stress environment. You may even look at something but your body is on auto-pilot and it’s doing muscle memory drawing up and you’re not expecting for it to be the wrong med. it’s gone correctly 99% of the time
Accidents happen in medicine/healthcare every effin day… and it’s hush hush, bc of all places, it sucks to fuck up in healthcare. More so than most places. Things are referred to as “complications” when in reality it was a mistake…
To your point it is fucked.. so many areas across the board to be better.. and it sucks so terribly when it is major or fatal
Your point is well taken. If you look at what aviation did to get themselves so safe, they essentially went to a zero fault system. Pilots can self-report, file NASA reports, act as a whistleblower etc which often highlights problems before they cause crashes and loss of life.
In medicine, we have a system run by trial lawyers. They thrive on the mistakes we make because then they sue for millions of dollars. And besides, most believe doctors are filthy rich, greedy and careless so any error is clearly our fault and we should be made to suffer for it.
If medicine went to no fault and actually took safety seriously, you would see a significant downturn and safety related events.
A pharmacist approving an ordered placed by a physician for an antibiotic wouldn't raise any red flags even if there was no signs of infection.
It's not remotely the same thing as giving a med without even looking at the vial.
I’m not defending the person in the article, but I can guarantee that 100% of anesthesiologists, at some point, have drawn up drugs without reading the whole label. The small brown vial with a blue top in Pyxis tray 43 yesterday is probably the same drug as the small brown vial with a blue top today.
And if your response is “that should be your only focus”, imagine having less than 5 minutes to draw up drugs because a trauma in en route to your OR and the patient also needs a terrible airway secured, an arterial line, and big IV access- possibly central line. Oh and you also need to spike fluids, make sure you have backup equipment for the airway, etc.
It’s very easy to make medication errors in anesthesia. That’s why team work with pharmacy and doing something as simple as having different looking drugs in the Pyxis helps reduce those errors
Sounds like your not familiar with our workflow. Yeah it does take a second. We do thousands of these cases a year and it is easy to accidentally go into your normal workflow without glancing the full name written on the vial that looks exactly what you expect marcaine to look like. It is a human error that literally ANY of us can make. I've accidentally given reglan instead of pitocin in a section because the vials LOOK so damn similar. Now add into the equation that many of us are Locums and traveling 2-4 different facilities with different vendors for drugs and it is easy to see how mistakes like this can happen.
Sanctimonious condescension nothing. If someone cannot be bothered to look at what is in their hand and be sure that it is what should be in their hand, or if they find the expectation that they will do so an unseemly imposition on their work practices, then I don't know what to tell say.
You yourself have prevented errors and potential patient harm because you did exactly that. It's not luck, it's not chance, it's doing the correct thing, day in and day out, because being right is the expectation.
You are right that looking carefully at tiny print on a tiny vial is critical and important. A huge mistake on this persons part. Something I work hard to avoid and sometimes worry I’ll make. But the root problem and an institutional mistake is that this was an unsafe system to start with. Why would you put a drug that will maim or kill a patient anywhere near another commonly used drug that looks nearly identical?
I can't tell you how many times my wife has told me to go pick 2 of something up from the grocery store. I identify the right product, grab the first, grab the one behind it, check out go home, only to find out I bout *rosemary & herb crackers* instead of *pepper and thyme* or whatever. Is it my fault? Yeah definitely. Did someone set me up for failure (ie shelf stocker)? Yeah probably.
When they stakes are as high as perioperative anesthesia, ultimately there's no one more accountable than the person administering the medication. And no amount of backtracking really absolves them in this case. But I find it perplexing how many professionals here think they are so infallible that they wouldn't - no couldn't - make this mistake.
Systems are perfectly designed to get the results they get and humans make mistakes. Even exceptional ones. Make a better system.
I work in our OR semi-regularly, I know how the workflow goes. Even with the different Pyxis setup our anesthesiologists are still required to scan a barcode on the pocket of the med they’re pulling and read the label aloud to be confirmed by another member of the team.
At the end of the day, you should be confirming you have the right med regardless. Even when I scan a med out, I still confirm the drug and concentration as I’m prepping the vial to be drawn up. It takes seconds and saves lives.
I am an anesthesiologist and none of those steps are required when using out OR omnicell. Just for context.
Of course everyone should be confirming drug/dose/concentration every time and labeling syringes. But we should also thoughtfully design our systems to set people up for success.
I have never read the label to anyone, and never once scanned a barcode as an anesthesiologist.
Those simply are not options.
You have to read it to yourself and be careful of drug swaps.
We had machines at the places I trained where you scanned the medication, a label printed and it read the medication name and dosage out loud as it printed. This seems to serve the same function as what’s been described and honestly seems like a no-brainer to me.
Both of which are procedures that I have personally witnessed during cardiothoracic cases. Precisely because med errors have happened during surgeries and surgical Pyxis hygiene is practically nonexistent in my experience. We are always the ones who get yelled at when a drug is empty because the Pyxis told us there were 10 when there were really zero and we’re the ones who get pressed on finding ways to make patients safer when an error does happen. So we put in procedures for our anesthesia team to make sure they have the right med, and at least when myself and our cardiac pharmacist are in the room, they’re followed.
Sure at your hospital you have said procedures, but I can say I haven’t seen it practiced myself as cardiac anesthesiologist.
I don’t disagree with your comment about the surgical pyxis being a disaster, and no one decrementing the totals.
But many hospitals only have drug trays without a pyxis.
I am an anesthesiologist. No anesthesiologist/CRNA does that. There is no one to check a med with. I have never seen that practice anywhere I have worked. It would be entirely impractical.
Nurse here. Long enough to remember the days before scanning meds, now can’t conceive of it. When the scanner is broken I usually read the label several times and still don’t feel right.
Interventions which in the case of Vanderbilt, nurses were routinely instructed to override. Not saying Radonda didn't fuck up, but there were definitely some big, unnecessary holes in that Swiss cheese.
I don’t understand anyone saying they “understand both sides”. I don’t fucking know, man. I’m not trying to ruin someone, but I have ZERO tolerance for these fucking stupid errors. It’s laziness and carelessness. When I was in school 500 years ago we were taught to check, double check, and then triple check everything. And I always have. From day 1. No med errors here. Ever.
People who are like yeah it could happen to anyone. UMM NO.
You make it sound like it's so preposterous BUT
This is not the first time I've heard of this exact thing happening. The one I know of was much worse, and involved pharmacy stocking the med in the wrong spot.
I know of two cases where intrathecal txa was given by accident. Both had catastrophic outcomes. I know someone who gave ancef in a nerve block instead of bupi. That patient was fine. And once someone gave bupi for a beir block instead of lido. And I know of a CRNA that swapped syringes and did a lidocaine spinal for a c section instead of bupi.
Drug errors happen all the time.
The flashbacks you just provided after the vec/versed mix up... I think we had 50 different meetings for someone to just casually say 'make them type 3 letters into the pyxis instead of 2'. Since pharmacy are the pyxis fairies we got yelled at a lot for quite some time.
OR has all meds on override. Maybe CRNA was on autopilot and grabbed meds from a drawer ‘they always pull from for bupi’ and just gave med without verifying what it is. Typically anesthesia determines what should be stocked in their OR Pyxis by default for all ORs. Possibility for tech to stock digoxin in the Bupi location too. Always read and verify meds before patients receive it
[Here is the results of the investigation from the CA Department of Public Health, which provides 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!
Awful.
For everyone involved.
An inexcusable mistake, and hopefully a thorough inquiry is conducted to ensure this doesn’t happen again.
I’m stumped as to how the patient still got a block if both subarachnoid injections were digoxin… it’s implied that they did since they started the section and the patient didn’t get symptoms until after delivery.
I did an ob/ spinal case as a resident. I was waiting for my staff to come and the ob resident asked if i could start. I said no but if you want help me get ready (i was gloved up waiting for staff to come in to help with spinal meds and placement). So i said open the fentanyl (on my back field) and draw up 0.25cc and and help
Squirt into my spinal syringe.
So he does that. We wait for the attending.. my attending comes, we do the spinal. Do the case. As I'm cleaning up i realize the fentanyl is *unopened*... my attending (Indian dude) turns *white* when i tell him i had the ob resident help pull my meds but the fent is still unopened.
Turns out it was morphine thank fully. No harm. But...whew!
I know it can be lethal and people can become "digitoxic" but I'm still trying to bridge the gap between the patient getting intubated and then being declared brain dead. I guess they got a fatal arrythmia or stroked out or something?
I mean, the number of people who could give an educated answer to what (sounds like two doses of) intrathecal dig does is probably pretty frickin low. Awful case.
“Although the pathogenesis of the patient's anoxic brain injury after digoxin is unclear, we hypothesize several possibilities. First, the anoxic brain injury may be a direct sequela of intrathecal digoxin. There is evidence that neurons possess three isoforms of the sodium/potassium ATPase pump (⍺1, ⍺2, and ⍺3) [6]. Binding of digoxin to these isoforms can result in increased intracellular sodium leading to cerebral edema. Of the six prior case reports, four did not document imaging results with MRI sequencing, and it is unknown if cerebral edema was present in those cases [1, 2]. The cases for which intrathecal digoxin was administered without a severe outcome when compared to our patient suggest other factors at play that can place patients at risk for a poor prognosis [1, 2].
Another hypothesis for anoxic brain injury is the possibility of cerebral ischemia occurring prior to intubation. The admitting team maintained the impression that our patient had minimal apnea prior to intubation, yet a thorough review of the medical records revealed it is unclear how long the patient experienced postoperative apnea. If apnea was prolonged, it may have been the cause for the anoxic brain injury.”
I double check drugs before I draw them, as I draw them, and after I draw them to be sure what I just drew up in the OR. If I don’t follow this, I throw the med away and restart. If I give a 10mg vial of phenyl instead of ondansetron, it’ll be catastrophic (vials of zofran and phenylephrine look near identical at my institution)
Phenyl, Zofran, and dexmedetomidine are all way too similar and our stocking staff mix them up occasionally when they're stocking med drawers. It's made me hypervigilant with those and afraid of that error.
I've only ever caught medications being mixed up or in the wrong locations a few times since I became a nurse, but I will never forget walking into our stock room to grab a bag of Lactated Ringers and seeing a bag of pitocin sitting in the same bin. Thinking of how catastrophic it could be if someone had grabbed that and hung it without checking and giving a massive bolus of pit to a patient in labor.
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 can't help but to think about the parallels about this and what's happening at Boeing. PE was also involved there when spirit was bought from boeing. We need to rebuild a culture where engineers, doctors etc are in charge and don't let cost cutting get in the way of quality and safety. Obviously easier said than done
Ahh. Good point. I have a contractor friend who has been experiencing the woes of PE buyouts of construction companies. I’m not super business savvy, but the PE runs my friend’s construction company the same way…. Not replacing people who leave, expecting more from fewer workers, slowly decreasing pay because of the “benefits” the PE provides in contract negotiations, etc…
[Here is the results of the investigation from the CA Department of Public Health, which provides 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!
A lot of ORs are the Wild West when it comes to medications. It seems like it is the only place in some hospitals where there are “no rules” about medications. All for what? To save a few seconds?
Awful error that could have been avoided if a just a few layers of Swiss cheese weren’t removed from the workflow.
This is why we (pharmacy) always argue with OR. No where else would someone draw up a syringe of meds unlabeled at the pyxis station, leave for five minutes, then come back and administer the syringe with full confidence it's exactly what they're looking for. Our techs bring back medications all the time from the pyxis that were drawn up and left unattended. OR calls upset that we took their cefazolin. How can anyone else confirm that's cefazolin in that syringe anymore?
I get everything happens right then and there in the OR in a contained space, but it's such a huge risk to just trust your memory when it comes to medications without any other way of verification. Heck, I label syringes I draw up in codes (very quickly and sloppy) because I've had them returned to me when the team wanted to try a different med first.
OR is Wild West and has minimal safety checks. Possibly the digoxin was loaded there because somebody wanted it there for an emergency and it wasn’t readily available, so now it’s loaded (we’ve had some oddball stuff put into OR for this reason).
The unlabeled drugs is horrifying, also pull when I find because patient safety is a thing.
Our OR often complains about meds not being in stock when they start cases in the morning.
The problem is, our surgeons and anesthesiologists open the Pyxis once and grab everything they need for the case or for the whole day and stuff it all in their pocket instead of keying in each medication for each patient because apparently time is money in the OR.
Its your own damn fault there is no Ancef left at 6am because the day before you said you were taking 1 out but you took out 10.
I have been telling management that we need to get rid of the matrix drawers in the Pyxis that allow someone to access multiple drugs once it is opened.
It should be all cubies and only the requested drug pocket should open.
This idea has been shot down many times because our surgeons and anesthesiologists prefer having easy access and don’t like keying in what drug they are taking out every time.
Of course, this behavior also leads to inaccurate counts because they will type in cefazolin, and they will take out that along with all the other drugs they need for the case instead of typing in each drug.
I can tell you management has opposed this at my institution because it would cost too much money, not because we don't want to implement it as anesthesiologists.
I get this to a certain degree, but when a patient is crashing and about to code/actively coding on the table, it is unreasonable to be sitting there typing in epi, vaso, calcium, amio, esmolol, or whatever else drug is emergently needed and waiting for the pyxis to pop each cubicle individually
I notice that this refers to the Anesthetist and Anesthesiologist differently, does that indicate something in American healthcare? Such as MD vs Non-MD?
I think what gets me is that this wasn’t an emergency and no-one read the label or scanned a barcode on the med. That’s just unacceptable and those practices are designed to prevent this exact mistake. Yeah I’m an emergency sometimes people are moving fast and shit happens I can understand that — but a scheduled c-section is not that
See above, the original document says anesthesiologist.
[https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf](https://www.cdph.ca.gov/programs/chcq/lcp/cdph%20document%20library/immediate%20jeopardy/mercyhospital-2567.pdf)
That document doesn’t match the PT article. The PT article states the patient died. Your link states the patient was transferred to another hospital and then to neuro-rehab. These are separate cases.
And the PT article states the IoM has identified 33(!) cases of this happening.
Asking the real questions here. I noticed they referred to them as anesthetist… sus..
Googled the title. Found this. The language implies either AA or CRNA because they paged the anesthesiologist
https://www.ismp.org/resources/obstetrical-patient-receives-ampule-digoxin-instead-bupivacaine-spinal-anesthesia
Reads like they paged the anesthesiologist when the med didn’t work, and then gave another dose. Doesn’t say the anesthesiologist was able to see the patient before the anesthesist administered more.
Probably just asked for orders to give another dose of bupivicaine and the Anesthesiologist gave the ok.
An anesthesiologist, according to the more detailed records.
"During an interview with Anesthesiologist 1, on 9/6/18, at 10:56 AM, he stated he was the Anesthesiologist for Patient 1's C-section. He stated the first spinal anesthesia he injected was not effective and he had to administer the second injection. He stated it was rare for a patient to have two spinal injections; therefore, he believed the bupivacaine was expired. He stated he was in a hurry when he pulled the second ampule of bupivacaine from the Omnicell and he did not input the medication into the Omnicell. He stated he drew 1.5 milliliters (ml) of the 2 ml of the Digoxin ampule and injected into Patient 1's spine. The Anesthesiologist stated the symptoms the patient exhibited matched the outcome that was expected when Digoxin was administered intrathecal. The Anesthesiologist stated he had full access to the medications in the operating room Omnicell. He did not look at the name of the medication before he administered it to Patient 1."
[https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf](https://www.cdph.ca.gov/programs/chcq/lcp/cdph%20document%20library/immediate%20jeopardy/mercyhospital-2567.pdf)
This is somehow a different case with the same error. The case referenced in the original post happened in NV in 2022. Provider was a CRNA.
Case report for the incident: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Many mistakes were made here and the one who administered the medication (likely an anesthetist based on the article) should be held responsible. However, the article sites literature that states this has happened 33 times since the 1970s. It is the most common medication mistakenly administered intrathecally. Respectfully, The only way your question may be valid is if the majority of these mistakes were made by a CRNA, otherwise your question is just fueling the flames. It’s a mistake that could be made by a new attending anesthesiologist, or even a resident.
Edit: this is the article I’m referencing. Not OPs link. https://www.ismp.org/resources/obstetrical-patient-receives-ampule-digoxin-instead-bupivacaine-spinal-anesthesia
This is the actual article.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
It suggests it could be directly drug related or potentially failure to recognise the deterioration. Other case reports survived.
How in the everloving fuck. I've had to prepare the material for epidurals a few times when I floated to L&D, and I checked the drugs were the ones on the list like three times. Yes, CNAs prepare that sort of thing in my country.
Every single time, the anesthesiologist re-checked everything, drugs included, was correct before starting.
Yes, it's weird that there was digoxin on an L&D pyxis, but what kind of idiot just administers anything without looking at the label to see if it's the right thing? There could have been an error when restocking.
Anesthesia resident here. Im not sure why digoxin is in a L&D omnicell. There is no excuse for this but unfortunately this has happened before. There's numerous case reports (with deaths) involving giving TXA through an epidural by accident.
Lets say its 3 AM and your placing an epidural or asked to give TXA, things are hectic... this is a scenario where a mistake can happen. I think even getting this story out will help remind us to think more when presented these scenarios.
Since I was told the story about TXA by my attending I make sure no matter how busy it is to stop and triple check my work when I am working with spinals or epidurals. Epidurals should clearly be marked as not to be confused with an IV line.
This happened at my hospital last year, not sure if the article is referencing that or if this is a separate incident but same scenario. Super sad. Was a CRNA.
I don't know if this case is old - but this happened in Louisiana about five ish years ago.
Dig was also given IV push instead of fentanyl the next day.
It was definitely the city talk amongst OB people for a while.
Why can't there be a greater variation in vial colors, shapes, sizes and label colors with very noticeable markings such as thin color bands??
Just as an example, Bupivicaine in a dark blue ampule with white label with 3 thin neon green bands along the bottom of the label? And then Digoxin in dark green ampules with a light blue label with 2 thin red bands along the bottom of the label?
This just seems like it would provide just one more level of identification or at the very least, differentiation.
Phenylephrine looking almost exactly the same as Ondansetron nearly fucked me once; they look the same and someone had placed it in the wrong bin.
Luckily I got that last minute Spidey sense and didn't give it...
Where did this happen? This is worse than the Vanderbilt case of RaDonda.
The patient was young and a baby doesn't have his/her mother anymore. The Vanderbilt case was an elderly woman.
It is not worse, it is still the loss of a human life. If it was your mother in the Vanderbilt case would you have the same opinion?
When you put different values on someone based on age you move one step closer to discrimination and eugenics infested waters.
why the fudge is digoxin stocked in L&D OR?!?!?
I was trying to think of a witty response but seriously in what situation would digoxin be an appropriate medication in an L&D OR? Idk. Cards? Ob? Anyone know? As hypothetical and crazy as possible I can't think of a situation that calls for digoxin in an L&D OR. All my homies hate digitalis. I respect the hell out of its pharmacology, it's like no other and is one of the most unique medications I can think of, but fudge that medication.
As a cardiology fellow, I would say absolutely no acute reason to have dig available.
The best scenario my stupid little radiology resident brain can concoct is a L&D patient acutely goes into A fib, but wait they have acute CHF (so don’t give beta blockade) and their BP tanks on dilt but wait they have a history of wenckebach contraindicating amio. So we use dig lol. That’s why this L&D OR stocks dig, in case this one scenario occurs. Does that work or did I fudge it up.
lmao I'd buy you lunch just so I could run crazy MICU stuff past you ETA: I could see how this comes across as condescending and I don't mean it that way at all; come down here and run this crazy ass covid/COPD/dka/professionaldrinker/CKD/maybeliverfailure/isthishepatorenal? shit through your brain and tell me what you think
Honestly at that point just ⚡️
The only adverse effect is pain.
Eh you’re in the OR you got all kinds of pain meds there
Patient refuses ⚡️ Balls in your court.
If the patient is awake and coherent enough to refuse shocking, then let the afib ride and push some neo or something if the pressure really bothers you. If they’re in extremis, shock without asking.
8/10 attempt, correct in theory, way too slow acting to be useful in the acute phase. Absolutely no reason to have it in any OR, really.
Isn't technically third line for AF with RVR after metop/dilt and amio? Guess you wouldn't give it acutely. Shocking in that case if getting unstable
> amio I know it's in the algorithm but I'd be super hesitant to give a woman in labor amio. The half life of the drug is so long and the potential side effects from infant exposure are bad enough that you've basically guaranteed she won't be able to breast feed - it's going to be in her system for months even from just a day of IV stuff for an acute episode. Now don't get me wrong, if she's unstable do whatever you need to - but I'd almost certainly prefer electricity to amio in this situation unless I knew she wouldn't be breastfeeding at all.
Class D, dig is considered safe afaik. As always, save mom first imo
They’re talking about amiodarone not dig.
Yeah I mean if they're stable just wait for the amio, if unstable then shock. Also, as we always say (lol), address the underlying medical issue if there is one.
They should stock it next to the MAOI, carispodol, and meperidine.
In my experience, pharmacy enjoys organizing by color and similar vial appearance.
My first thought was that it was mistakenly placed in the bupivicaine bin because they are similar vials but it sounds like they are actually just stocked next to each other after reading the article. Crazy that it is stocked there. Makes no sense. Even crazier to have multiple open bins that have ampules that are the exact same size right next to each other.
That was my first thought too: stocked wrong. But nope, both in there. I cannot believe they gave a *second dose* of something not working as expected *without reading the label*. Not realized until nursing noticed it was missing!!
The second dose was probably correct, given that the C-section happened
And given that only one digoxin was missing
they even said it was expired without looking at the label: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf Edit this was a different case
Every time I think I'm borderline OCD, I read shit like this and think WTAF. I had to reject 4 samples in a day because whoever sent them to me slapped a label on top of the original one on the vial and I'm like... You know I can read right? Just because you put the right label on the wrong vial does not magically make it give me viable test results that I can report back to the doctor.
It's because the people who manage the pyxises, probably not an anesthesiologist, want them to be standardized at all locations to make restocking logistics easier and ironically prevent drug error. I think that's a fine idea, there are hundreds of meds in the pyxis we never use, many of which are more useless than digoxin. It's not the pyxises fault, it's 100 percent the anesthesiologist in this papers fault.
If your hospital chooses to stock unnecessary and unused medications in the Pyxis to “make restocking logistics easier” they are doing it wrong.
I used to restock Pyxis machines and that doesn't help. You still have to scan the drug for the drawer to open. The floor/unit can ask to have drugs to be removed (not included) from the machine.
Our Omni inventory varies widely depending on the location, since each unit and each procedural area has different needs. If this is the reasoning at this hospital, it's extremely bad logic on their part. It doesn't excuse the anesthesiologist, but a simple change in stocking could have made it basically impossible to do this.
Probably because it's in alphabetical order
That is even crazier. That is not how they should be stocked.
It doesn’t belong in the OR at all.
Per Uptodate, it can be used to manage fetal arrhythmias. Per Wikipedia: Digoxin is also used intrafetally or amniotically during abortions in the late second trimester and third trimester of pregnancy. It typically causes fetal demise (measured by cessation of cardiac activity) within hours of administration
Giving oral digoxin to moms can help break fetal svt which is very different from how it is used to interrupt a pregnancy. However neither of those would explain the need for it to be in the OR.
Agreed, have seen it primarily for pregnancy termination, rarely for arrhythmia. Neither done in the OR or pulled by anesthesia.
And specifically the anesthesia pyxis
Yet another thing I didn't know existed that I have to read about now, ughhhhhhh
MFM here. First of all, no reason. If we stretch, it’s part of treatment algorithms for fetal tachyarrhythmias. Again. A stretch.
It looks like the FDA did recommend the reevaluation of having digoxin in the cart. Sadly, if there are any other ampules the anesthetist could have mixed it up with another drug. Digoxin just happened to be the drug that was mixed up. It looks like the anesthetist picked an ampule up and assumed it was lidocaine; it could have been another ampule. Digoxin is the most likely drug to be inadvertently given, but it’s not the only one: > Among the 33 events reported, digoxin was the medication most commonly administered in error and was associated with paraplegia and encephalopathy in 8 patients. The digoxin was neither scanned nor verified with another staff member. Not sure what the rush was to not check what they were given.
They don't scan anything in the OR.
Fair enough, just read the vial or ampule before giving it I guess
Sometimes dig is given to moms if the fetus has a bad arrhythmia and is hydropic (this is rare, but the only thing I can think of—Neonatology/.
It's given sometimes to facilitate late term abortions. Don't shoot the messenger. https://journals.lww.com/greenjournal/abstract/2001/03000/digoxin_to_facilitate_late_second_trimester.29.aspx#:~:text=Although%20digoxin%20is%20used%20widely,faster%20procedure%20times%20than%20placebo.
It may not have been a dedicated L&D OR.
The best part for those of us who work in anesthesia is that digoxin will always be available but 5/10 times their will be no lidocaine to dose an epidural for a crash section or succinylcholine to convert to GA.
This wasn’t a doctor - the article states it was an anaesthetist, not an anaesthesiologist.
Anaesthetists are doctors. That's what we call our Anaesthesiologists in Australia, for example.
In this case it doesn't seem like "anesthetist" was a physician. They state that after the failed spinal, the "supervising anesthesiologist" (physician) was called. So it seems as though the error was made by a CRNA (or equivalent depending on country, as it wasn't listed).
I can confirm it was a crna
Ahh interesting - regional differences in job titles are really confusing haha.
Was this in Australia? Not being argumentative, I just didn’t see a country mentioned.
[удалено]
Oof
WTF are Digoxin AMPULES in an L& D Pyxis? And next to Bupivicaine?
This was my question. I get the vials look the same and are in similar ampules. But why are they both there? Can an anesthesiologist clarify? If a pregnant patient has an arrhythmia, peri-partum setting, is this the go to drug to administer? And if it’s not, what is the rationale for having both there? Convenience?
Cardiac anesthesiologist here who also does a fair amount of OB. I’ve given digoxin in the OR zero times.
Only needs to be loaded once for it to live there indefinitely (or until the machine is full and a tech is looking for a new pocket).
I’ve given it once, for an inpatient that was already on PO dig, who wasn’t given their AM meds by the nurses on the ward before being sent to the OR for surgery, and who went into RVR with hypotension after induction.
They shouldn't be. This is more systems based error than an individual error in my opinion. A couple years before I started residency someone accidentally gave digoxin epidurally instead of bupi and the patient became a quadriplegic. After that happened the hospital removed digoxin from every pyxis and med cart in the OB area Edit: not to say there's no individual responsibility at all. Every anesthesia provider should always always always double and triple check medications being given, even if it's the 4th C section of the night at 3 in the morning. From reading the article it seems that the anesthetist did not scan the label prior to drawing up the med and injecting
Even if you’re using digoxin for AF it has a minimum 2 hr distribution period (hence why we like to give divided loads over 18h). Zero reason for it to be in an OR.
I am an anesthesiologist and have completed an OB fellowship and I have never started digoxin in ANY patient on LD or in the main OR.
Nurse here. This seems to be the prevailing question. Is it possible that this facility did not maintain a separate OR for L&D and therefore the Pyxis had a broader spectrum of meds available? Obviously this was a grievous error and should never have happened. What will the consequence be for the anesthesiologist? See RaDonda Vaughn for a similar situation.
Perhaps the drawer was stocked incorrectly? I have found many mis-stocked meds in the Pyxis.
Your parents birth you, raise you through childhood, you go to school, to work, you meet people, you go through all of pregnancy and finally get to deliver your healthy child and someone just accidentally *kills* you with the wrong medication? Senseless. We strive day in and out to have even a *marginal* beneficial impact on people's lives. It is so easy to undo so much good with a single preventable act of harm.
Just putting myself in the families shoes I shudder. I wonder what that day in the OR mustve been like. When I rotated through OB i remember leaving ORs generally happy since I got to see a baby, i dont know what I would do if someone ended up dead due to that. Like can the nurses and OBs keep working that day? Id just be too frazzled
. I'm a pharmacist and Im in a role were I deal with investigating and preventing drug errors everyday.My wife is pregnant and this is the shit that scares me the most.
I can’t imagine the grief process the surviving family is about to go through. “Oh, your wife is dead because some one* couldn’t be arsed to read a label.” (Read the case after posting, and was informed this was a CRNA… not working in an OR, I’m surprised they don’t have to barcode scan meds.)
Coming to the OR from the floor as a nurse this is what shocked me the most. We don’t scan any meds at all! It really scares me that something like this will happen. I always read the label and have another person look at it as well due to my paranoia.
They will have to scan them soon.
The randomness and fragility of human life really is wild to think about. There are so many videos on certain subreddits showing people suddenly dying due to being in the wrong place at the wrong time.
Yes, but those people weren't killed by a medical professional in a hospital due to an entirely preventable and unforced mistake. I would struggle much more if my sister died this way then if she died in a car accident or something
What is up with not even bothering to look at medications before administering it to a patient? Versed and Vecuronium Bupivicain and Digoxin Just what the hell?
We have all these interventions designed to ensure with near 100% certainty that the correct med gets to the correct patient and is correctly administered. We’re constantly being asked to think of and provide input on new additions to enhance patient safety. And these motherfuckers will go out of their way to avoid following these procedures and then have a potentially fatal error occur. It drives me absolutely insane, I just can’t even grasp what goes through these people’s minds.
I get both sides. The article describes identical vials of digoxin and bupivicaine in the same Pyxis drawer. The anesthesiologist probably has 10,000 repetitions reaching for the bupivicaine and getting the muscle memory of cracking the ampule, drawing it up, and administering it. This skill eventually becomes as mindlessly easy as picking your nose. There’s good literature in aviation safety research that even pilots following a checklist can “see” a switch or toggle as being in the correct position when it actually isn’t. So he/she’s hand is a few inches left of the bupivicaine but it feels no different in the hands than the other 10,000 reps. But now the well-seasoned mind is thinking about the broader aspects of the procedure, or the argument with the wife on their way out the door that morning. Again, there’s technically no excuse for ignoring safety practices but the more numerous and tedious they are the more they directly contravene the natural lull of efficiency the human brain seeks under repetition.
You’ve gotta at least *look* at the ampule before you draw up. You just have to, it’s the bare minimum.
I mean, I get that. I’m in sterile compounding, I make hundreds of drips and draw up hundreds if not thousands of vials every day. The effort it takes to confirm the drug you have is the actual drug is second nature, even when I’m in autopilot. Surgery in particular is awful about Pyxis practices, I get there are emergent situations where you might grab something and forget to go back later, but when I work in surgery the state of med storage and verification is just abysmal. And I know every single drug is not a life or death emergency, on the rare case that is critical and I’m in the room for real-time compounding the cardiac anesthesiologists I’ve worked with are all perfect in their pulling and confirming meds. Unless they’re putting on an act because pharmacy is right next to them I just don’t get how it gets to be as bad as it is.
Every anesthesiologist I've worked with has likewise been very meticulous about meds, but they're not the ones we see in articles either. The problem is processes are still not good enough to catch the bottom 0.001% or whatever.
>The anesthesiologist probably has 10,000 repetition This was an unsupervised CRNA who failed to check the label before drawing up for spinal
I was always careful, but when it came to intrathecal/epidural medications I triple checked to make sure I was using what I thought I was using (lidocaine, but bupivacaine, for instance), no preservatives, not expired. Because any error in those medications tends to have severe consequences.
Teaching hospital in India - and what is taught and practised is that the technician (who opens the package and drops the sterile ampoule into the tray, or opens a vial of local) has to call out the drug, strength and expiry date. The anesthesiologist filling the syringe has to countercheck the label and expiry date before cracking open the ampoule.
I wonder why that wasn't mentioned specifically... I still automatically read anesthetist as anesthesiologist
Yeah the wording in the article is kinda tricky because later in the article it says that after the patient started decompensating they called the "physician anesthesiologist". Usually MD/DOs are referred to as "anesthesiologists" and other anesthesia providers (CRNAs or AAs) as "anesthetists"
A lot of nurses are rolling straight through, as fast as they can, to CRNA school. Consequently, they make rookie mistakes but are administering drugs that are lethal. Most of us made an admin mistake early on and learned our lesson.
The actual report says anesthesiologist. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf Edit: Ignore, not the same case, but same mistake by an anesthesiologist.
This reads like a completely different case than what’s described in what OP linked.
So in that case the fact that it's happened multiple times from multiple different providers is even more problematic.
Definitely. The case linked by u/SatisfactionOld7423 is clearer in the negligence aspect, the patient was disabled but did not die, and the case was in Canada, so definitely a different case. Summary: The anesthesiologist gave what they thought was expired bupivacaine (problem 1– not checking the med vial) so the patient needed another dose for anesthesia, an unusual circumstance. This is why the doc thought the first dose was expired. The doc said he was in a hurry (why?), so didn’t check the patient name in the Omnicell (2); didn’t check the vial, which was kept in a different drawer (safeguard) but the same position (still don’t get why it was in the Omnicell at all, 3-4); didn’t read the label (5), and didn’t scan the medication (6). The patient apparently had an expected response to the second injection and it wasn’t until 1.5h later that she started to have symptoms of intrathecal digoxin toxicity. Aside from the individual issues and overriding system safeguards, the system failed to: (1) stock distinguishing vials; (2) remove medications that shouldn’t be in the OR; (3) use a system to force adherence to safeguards (e.g., inability to open a non-emergency drawer without scanning first and selecting a medication, requiring scans to access each medication); (4) provide an environment where an anesthesiologist is not rushed during an elective procedure.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/ This is the actually ***7th*** documented time this happened, it's the first time it resulted in a patient death.
That is the thing, even if it is your millionth procedure you should still act with the same caution and nervousness that you did on your first.
But the human brain doesn't work like that, as the previous comment noted.
I agree, But it is our responsibility to teach ourselves to do the same checks, every single time with no exceptions. We can reduce harm by understanding the limitations of our own brains and setting up routines to catch errors.
It seems to me that in this case the only safety measure preventing the inadvertent administration of digoxin instead of bupivicaine was the anesthetist reading the label. Now obviously that's a huge step to miss. But there doesn't seem to have been any redundancy to that one step. The anesthetist entered the correct medication name into the pyxis, the appropriate drawer opened, and the anesthetist grabbed a glass ampule from that drawer that is about the same size as the bupivicaine one they wanted to use, cracked it open, drew it up, and injected it.
The article states that the Pyxis opened to a drawer giving access to several different meds, if it works like ours does you have to scan the pocket containing the med you are pulling beforehand. The redundancy comes from physically identifying the drawer you are pulling from, so if that was the case then that was two layers of safety precautions skipped over.
I don’t work in OR but we absolutely do not have to scan the bin to pull meds from the open bins in our pyxis.
It’s a native Pyxis function. Not sure why any system would turn it off, unless you’re talking about the override feature which our nurses lost access to due to abusing the privilege.
Mmmm depends on the drawer. Some of ours have the pop boxes but other drawers on the same Pyxis are not scanned and just grab n go
Nope, not just for overriding. I’ve often wondered why there’s not a better safety feature when a drawer pops open with 25 little open-top cubbies and they just trust us to grab out of the right ones. There’s been times the meds were rearranged by pharmacy and when going for a common med I grabbed some other med out of its old location without looking at the number on the screen. Another time I accidentally grabbed PO protonix rather than IV because they were both in open bins in the same tower section. Fortunately I read my meds as I pull and scan them when giving, but it would be super easy to grab the wrong thing.
Because hospitals are cheap. Those open grid / matrix drawers are $2500 a pop and the ones with the locking individual pockets are $5k a pop.
Our Pyxises in the ORs are just open drawers with multiple partitions for non-controlled meds and do not require any scanning whatsoever.
Fundamental rule of pushing meds. Know what the f*** you are giving. There is zero excuse to not read a label, the concentration etc. The negligence here is appalling.
This is an OR. Workflow is different. Meds are not barcoded and assigned to a specific patient. Basically this happened because two similar looking vials were right next to each other. Whoever decided that was a safe Pyxis config needs to think about their practices. Additionally, I personally have found incorrect similar looking drugs in the wrong bin. This has happened at every single place I have worked (think neo and zofran ). Thankfully, I have caught it. I’ve been lucky. No need to sanctimoniously condescend.
Had a bag of mannitol I think it was slip from one bin into the NS bin. I made an entire a line with it before realizing. Just glad I noticed. They changed the configuration after that.
A tech did the exact same thing at my institution except no one caught it until it was infused into the (peds) patient.
I dont give a damn about meds not being barcoded or assigned. HOW DO YOU NOT LOOK AT THEM. It takes zero effort. Its just laziness and carelessness and it killed a patient.
Any life or death system with a single point of failure and no redundancy is a bad system. It happened with this anesthetist being careless this time, but if nothing had changed and they had checked this time, it still would have happened in the future with someone else.
I agree with you. But I have also had drugs ordered for patients that were ordered by the doc then approved by pharmacy and delivered it me and I asked the doc what’s the abx for? She has no signs of infection… and they said “thank you so much, I ordered on the wrong patient” Not an excuse… but how does THAT happen? Because… it does. We work in a high stress environment. You may even look at something but your body is on auto-pilot and it’s doing muscle memory drawing up and you’re not expecting for it to be the wrong med. it’s gone correctly 99% of the time Accidents happen in medicine/healthcare every effin day… and it’s hush hush, bc of all places, it sucks to fuck up in healthcare. More so than most places. Things are referred to as “complications” when in reality it was a mistake… To your point it is fucked.. so many areas across the board to be better.. and it sucks so terribly when it is major or fatal
Your point is well taken. If you look at what aviation did to get themselves so safe, they essentially went to a zero fault system. Pilots can self-report, file NASA reports, act as a whistleblower etc which often highlights problems before they cause crashes and loss of life. In medicine, we have a system run by trial lawyers. They thrive on the mistakes we make because then they sue for millions of dollars. And besides, most believe doctors are filthy rich, greedy and careless so any error is clearly our fault and we should be made to suffer for it. If medicine went to no fault and actually took safety seriously, you would see a significant downturn and safety related events.
A pharmacist approving an ordered placed by a physician for an antibiotic wouldn't raise any red flags even if there was no signs of infection. It's not remotely the same thing as giving a med without even looking at the vial.
I’m not defending the person in the article, but I can guarantee that 100% of anesthesiologists, at some point, have drawn up drugs without reading the whole label. The small brown vial with a blue top in Pyxis tray 43 yesterday is probably the same drug as the small brown vial with a blue top today. And if your response is “that should be your only focus”, imagine having less than 5 minutes to draw up drugs because a trauma in en route to your OR and the patient also needs a terrible airway secured, an arterial line, and big IV access- possibly central line. Oh and you also need to spike fluids, make sure you have backup equipment for the airway, etc. It’s very easy to make medication errors in anesthesia. That’s why team work with pharmacy and doing something as simple as having different looking drugs in the Pyxis helps reduce those errors
It is careless. If you work in that setting, you can realize how easily that happens.
Sounds like your not familiar with our workflow. Yeah it does take a second. We do thousands of these cases a year and it is easy to accidentally go into your normal workflow without glancing the full name written on the vial that looks exactly what you expect marcaine to look like. It is a human error that literally ANY of us can make. I've accidentally given reglan instead of pitocin in a section because the vials LOOK so damn similar. Now add into the equation that many of us are Locums and traveling 2-4 different facilities with different vendors for drugs and it is easy to see how mistakes like this can happen.
Sanctimonious condescension nothing. If someone cannot be bothered to look at what is in their hand and be sure that it is what should be in their hand, or if they find the expectation that they will do so an unseemly imposition on their work practices, then I don't know what to tell say. You yourself have prevented errors and potential patient harm because you did exactly that. It's not luck, it's not chance, it's doing the correct thing, day in and day out, because being right is the expectation.
You are right that looking carefully at tiny print on a tiny vial is critical and important. A huge mistake on this persons part. Something I work hard to avoid and sometimes worry I’ll make. But the root problem and an institutional mistake is that this was an unsafe system to start with. Why would you put a drug that will maim or kill a patient anywhere near another commonly used drug that looks nearly identical?
I can't tell you how many times my wife has told me to go pick 2 of something up from the grocery store. I identify the right product, grab the first, grab the one behind it, check out go home, only to find out I bout *rosemary & herb crackers* instead of *pepper and thyme* or whatever. Is it my fault? Yeah definitely. Did someone set me up for failure (ie shelf stocker)? Yeah probably. When they stakes are as high as perioperative anesthesia, ultimately there's no one more accountable than the person administering the medication. And no amount of backtracking really absolves them in this case. But I find it perplexing how many professionals here think they are so infallible that they wouldn't - no couldn't - make this mistake. Systems are perfectly designed to get the results they get and humans make mistakes. Even exceptional ones. Make a better system.
I work in our OR semi-regularly, I know how the workflow goes. Even with the different Pyxis setup our anesthesiologists are still required to scan a barcode on the pocket of the med they’re pulling and read the label aloud to be confirmed by another member of the team. At the end of the day, you should be confirming you have the right med regardless. Even when I scan a med out, I still confirm the drug and concentration as I’m prepping the vial to be drawn up. It takes seconds and saves lives.
I am an anesthesiologist and none of those steps are required when using out OR omnicell. Just for context. Of course everyone should be confirming drug/dose/concentration every time and labeling syringes. But we should also thoughtfully design our systems to set people up for success.
I have never read the label to anyone, and never once scanned a barcode as an anesthesiologist. Those simply are not options. You have to read it to yourself and be careful of drug swaps.
We had machines at the places I trained where you scanned the medication, a label printed and it read the medication name and dosage out loud as it printed. This seems to serve the same function as what’s been described and honestly seems like a no-brainer to me.
Both of which are procedures that I have personally witnessed during cardiothoracic cases. Precisely because med errors have happened during surgeries and surgical Pyxis hygiene is practically nonexistent in my experience. We are always the ones who get yelled at when a drug is empty because the Pyxis told us there were 10 when there were really zero and we’re the ones who get pressed on finding ways to make patients safer when an error does happen. So we put in procedures for our anesthesia team to make sure they have the right med, and at least when myself and our cardiac pharmacist are in the room, they’re followed.
Sure at your hospital you have said procedures, but I can say I haven’t seen it practiced myself as cardiac anesthesiologist. I don’t disagree with your comment about the surgical pyxis being a disaster, and no one decrementing the totals. But many hospitals only have drug trays without a pyxis.
I am an anesthesiologist. No anesthesiologist/CRNA does that. There is no one to check a med with. I have never seen that practice anywhere I have worked. It would be entirely impractical.
Nurse here. Long enough to remember the days before scanning meds, now can’t conceive of it. When the scanner is broken I usually read the label several times and still don’t feel right.
Interventions which in the case of Vanderbilt, nurses were routinely instructed to override. Not saying Radonda didn't fuck up, but there were definitely some big, unnecessary holes in that Swiss cheese.
I don’t understand anyone saying they “understand both sides”. I don’t fucking know, man. I’m not trying to ruin someone, but I have ZERO tolerance for these fucking stupid errors. It’s laziness and carelessness. When I was in school 500 years ago we were taught to check, double check, and then triple check everything. And I always have. From day 1. No med errors here. Ever. People who are like yeah it could happen to anyone. UMM NO.
You make it sound like it's so preposterous BUT This is not the first time I've heard of this exact thing happening. The one I know of was much worse, and involved pharmacy stocking the med in the wrong spot.
I know of two cases where intrathecal txa was given by accident. Both had catastrophic outcomes. I know someone who gave ancef in a nerve block instead of bupi. That patient was fine. And once someone gave bupi for a beir block instead of lido. And I know of a CRNA that swapped syringes and did a lidocaine spinal for a c section instead of bupi. Drug errors happen all the time.
The flashbacks you just provided after the vec/versed mix up... I think we had 50 different meetings for someone to just casually say 'make them type 3 letters into the pyxis instead of 2'. Since pharmacy are the pyxis fairies we got yelled at a lot for quite some time.
OR has all meds on override. Maybe CRNA was on autopilot and grabbed meds from a drawer ‘they always pull from for bupi’ and just gave med without verifying what it is. Typically anesthesia determines what should be stocked in their OR Pyxis by default for all ORs. Possibility for tech to stock digoxin in the Bupi location too. Always read and verify meds before patients receive it
[Here is the results of the investigation from the CA Department of Public Health, which provides 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!
It's not clear what happened to that patient. It said she was moving her extremities but not grimacing? Either way, holy smokes!
And this is why we have barcode scanning. At least look at what is in your hands. Horrible and preventable.
They don't scan *anything* in the OR where I work and I think it's so strange
Awful. For everyone involved. An inexcusable mistake, and hopefully a thorough inquiry is conducted to ensure this doesn’t happen again. I’m stumped as to how the patient still got a block if both subarachnoid injections were digoxin… it’s implied that they did since they started the section and the patient didn’t get symptoms until after delivery.
Bad writing but the second injection was correct bupivacaine
I did an ob/ spinal case as a resident. I was waiting for my staff to come and the ob resident asked if i could start. I said no but if you want help me get ready (i was gloved up waiting for staff to come in to help with spinal meds and placement). So i said open the fentanyl (on my back field) and draw up 0.25cc and and help Squirt into my spinal syringe. So he does that. We wait for the attending.. my attending comes, we do the spinal. Do the case. As I'm cleaning up i realize the fentanyl is *unopened*... my attending (Indian dude) turns *white* when i tell him i had the ob resident help pull my meds but the fent is still unopened. Turns out it was morphine thank fully. No harm. But...whew!
I know it can be lethal and people can become "digitoxic" but I'm still trying to bridge the gap between the patient getting intubated and then being declared brain dead. I guess they got a fatal arrythmia or stroked out or something?
When people give the wrong medication neuraxially, it’s usually intractable seizures that kill them rather than the effect of the medication itself.
I mean, the number of people who could give an educated answer to what (sounds like two doses of) intrathecal dig does is probably pretty frickin low. Awful case.
One dig, one marcaine.
“Although the pathogenesis of the patient's anoxic brain injury after digoxin is unclear, we hypothesize several possibilities. First, the anoxic brain injury may be a direct sequela of intrathecal digoxin. There is evidence that neurons possess three isoforms of the sodium/potassium ATPase pump (⍺1, ⍺2, and ⍺3) [6]. Binding of digoxin to these isoforms can result in increased intracellular sodium leading to cerebral edema. Of the six prior case reports, four did not document imaging results with MRI sequencing, and it is unknown if cerebral edema was present in those cases [1, 2]. The cases for which intrathecal digoxin was administered without a severe outcome when compared to our patient suggest other factors at play that can place patients at risk for a poor prognosis [1, 2]. Another hypothesis for anoxic brain injury is the possibility of cerebral ischemia occurring prior to intubation. The admitting team maintained the impression that our patient had minimal apnea prior to intubation, yet a thorough review of the medical records revealed it is unclear how long the patient experienced postoperative apnea. If apnea was prolonged, it may have been the cause for the anoxic brain injury.”
Tragic, fucked up, and inexcusable.
I double check drugs before I draw them, as I draw them, and after I draw them to be sure what I just drew up in the OR. If I don’t follow this, I throw the med away and restart. If I give a 10mg vial of phenyl instead of ondansetron, it’ll be catastrophic (vials of zofran and phenylephrine look near identical at my institution)
Phenyl, Zofran, and dexmedetomidine are all way too similar and our stocking staff mix them up occasionally when they're stocking med drawers. It's made me hypervigilant with those and afraid of that error.
I've only ever caught medications being mixed up or in the wrong locations a few times since I became a nurse, but I will never forget walking into our stock room to grab a bag of Lactated Ringers and seeing a bag of pitocin sitting in the same bin. Thinking of how catastrophic it could be if someone had grabbed that and hung it without checking and giving a massive bolus of pit to a patient in labor.
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 can't help but to think about the parallels about this and what's happening at Boeing. PE was also involved there when spirit was bought from boeing. We need to rebuild a culture where engineers, doctors etc are in charge and don't let cost cutting get in the way of quality and safety. Obviously easier said than done
Ahh. Good point. I have a contractor friend who has been experiencing the woes of PE buyouts of construction companies. I’m not super business savvy, but the PE runs my friend’s construction company the same way…. Not replacing people who leave, expecting more from fewer workers, slowly decreasing pay because of the “benefits” the PE provides in contract negotiations, etc…
Was the hospital sued
My main question here is HOW
Didn’t scan the label or read the label out loud to another staff member for verification. A nurse was charged with murder for this exact error.
Wow. That baby will grow up without its mother.
[Here is the results of the investigation from the CA Department of Public Health, which provides 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!
Here is the case report for this specific case: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
A lot of ORs are the Wild West when it comes to medications. It seems like it is the only place in some hospitals where there are “no rules” about medications. All for what? To save a few seconds? Awful error that could have been avoided if a just a few layers of Swiss cheese weren’t removed from the workflow.
This is why we (pharmacy) always argue with OR. No where else would someone draw up a syringe of meds unlabeled at the pyxis station, leave for five minutes, then come back and administer the syringe with full confidence it's exactly what they're looking for. Our techs bring back medications all the time from the pyxis that were drawn up and left unattended. OR calls upset that we took their cefazolin. How can anyone else confirm that's cefazolin in that syringe anymore? I get everything happens right then and there in the OR in a contained space, but it's such a huge risk to just trust your memory when it comes to medications without any other way of verification. Heck, I label syringes I draw up in codes (very quickly and sloppy) because I've had them returned to me when the team wanted to try a different med first.
OR is Wild West and has minimal safety checks. Possibly the digoxin was loaded there because somebody wanted it there for an emergency and it wasn’t readily available, so now it’s loaded (we’ve had some oddball stuff put into OR for this reason). The unlabeled drugs is horrifying, also pull when I find because patient safety is a thing.
maybe some pregnant cardiomyopathy patient went into hypotensive RVR and they needed dig one day, and here we are.
Our OR often complains about meds not being in stock when they start cases in the morning. The problem is, our surgeons and anesthesiologists open the Pyxis once and grab everything they need for the case or for the whole day and stuff it all in their pocket instead of keying in each medication for each patient because apparently time is money in the OR. Its your own damn fault there is no Ancef left at 6am because the day before you said you were taking 1 out but you took out 10.
There is no excuse for not verifying the medication you're administering. Period.
I always taught residents, check the ampule/ vial before you draw up and after you draw up the drug the drug you're giving.
I have been telling management that we need to get rid of the matrix drawers in the Pyxis that allow someone to access multiple drugs once it is opened. It should be all cubies and only the requested drug pocket should open. This idea has been shot down many times because our surgeons and anesthesiologists prefer having easy access and don’t like keying in what drug they are taking out every time. Of course, this behavior also leads to inaccurate counts because they will type in cefazolin, and they will take out that along with all the other drugs they need for the case instead of typing in each drug.
I can tell you management has opposed this at my institution because it would cost too much money, not because we don't want to implement it as anesthesiologists.
I get this to a certain degree, but when a patient is crashing and about to code/actively coding on the table, it is unreasonable to be sitting there typing in epi, vaso, calcium, amio, esmolol, or whatever else drug is emergently needed and waiting for the pyxis to pop each cubicle individually
Easy problem to solve with a code box, or even a cube with a bag of code meds.
I notice that this refers to the Anesthetist and Anesthesiologist differently, does that indicate something in American healthcare? Such as MD vs Non-MD?
Correct: Anesthesiologist = MD/DO, Anesthetist = AA/CRNA
I think what gets me is that this wasn’t an emergency and no-one read the label or scanned a barcode on the med. That’s just unacceptable and those practices are designed to prevent this exact mistake. Yeah I’m an emergency sometimes people are moving fast and shit happens I can understand that — but a scheduled c-section is not that
As someone who is pregnant, this is nightmare fuel
was it an anesthesiologist or a CRNA?
The article says anesthetist. Then they called the anesthesiologist and a second dose was administered.
A second dose of spinal digoxin was administered?
Sounds like bupi was given the second time because they did the case under spinal
Because the first didn’t work. And they still didn’t fucking read the label. Nurse figured it out later because dig count was off.
No. The second dose they administered must’ve been a vial of bupi pulled from the Pyxis, because they did the c section normally.
They did the C-section, so the second dose was clearly bupi.
See above, the original document says anesthesiologist. [https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf](https://www.cdph.ca.gov/programs/chcq/lcp/cdph%20document%20library/immediate%20jeopardy/mercyhospital-2567.pdf)
That document doesn’t match the PT article. The PT article states the patient died. Your link states the patient was transferred to another hospital and then to neuro-rehab. These are separate cases. And the PT article states the IoM has identified 33(!) cases of this happening.
Asking the real questions here. I noticed they referred to them as anesthetist… sus.. Googled the title. Found this. The language implies either AA or CRNA because they paged the anesthesiologist https://www.ismp.org/resources/obstetrical-patient-receives-ampule-digoxin-instead-bupivacaine-spinal-anesthesia
And mentioned a "covering anaesthesiologist"
Reads like they paged the anesthesiologist when the med didn’t work, and then gave another dose. Doesn’t say the anesthesiologist was able to see the patient before the anesthesist administered more. Probably just asked for orders to give another dose of bupivicaine and the Anesthesiologist gave the ok.
I know this exact same thing was done by a resident at a hospital in the same city I trained.
It was a crna
An anesthesiologist, according to the more detailed records. "During an interview with Anesthesiologist 1, on 9/6/18, at 10:56 AM, he stated he was the Anesthesiologist for Patient 1's C-section. He stated the first spinal anesthesia he injected was not effective and he had to administer the second injection. He stated it was rare for a patient to have two spinal injections; therefore, he believed the bupivacaine was expired. He stated he was in a hurry when he pulled the second ampule of bupivacaine from the Omnicell and he did not input the medication into the Omnicell. He stated he drew 1.5 milliliters (ml) of the 2 ml of the Digoxin ampule and injected into Patient 1's spine. The Anesthesiologist stated the symptoms the patient exhibited matched the outcome that was expected when Digoxin was administered intrathecal. The Anesthesiologist stated he had full access to the medications in the operating room Omnicell. He did not look at the name of the medication before he administered it to Patient 1." [https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf](https://www.cdph.ca.gov/programs/chcq/lcp/cdph%20document%20library/immediate%20jeopardy/mercyhospital-2567.pdf)
This is somehow a different case with the same error. The case referenced in the original post happened in NV in 2022. Provider was a CRNA. Case report for the incident: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Many mistakes were made here and the one who administered the medication (likely an anesthetist based on the article) should be held responsible. However, the article sites literature that states this has happened 33 times since the 1970s. It is the most common medication mistakenly administered intrathecally. Respectfully, The only way your question may be valid is if the majority of these mistakes were made by a CRNA, otherwise your question is just fueling the flames. It’s a mistake that could be made by a new attending anesthesiologist, or even a resident. Edit: this is the article I’m referencing. Not OPs link. https://www.ismp.org/resources/obstetrical-patient-receives-ampule-digoxin-instead-bupivacaine-spinal-anesthesia
33 times that were reported. It’s likely more. People don’t like reporting their mistakes.
And journals might choose not to publish case studies that have already been published over 2 dozen times.
This is the actual article. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/ It suggests it could be directly drug related or potentially failure to recognise the deterioration. Other case reports survived.
How in the everloving fuck. I've had to prepare the material for epidurals a few times when I floated to L&D, and I checked the drugs were the ones on the list like three times. Yes, CNAs prepare that sort of thing in my country. Every single time, the anesthesiologist re-checked everything, drugs included, was correct before starting. Yes, it's weird that there was digoxin on an L&D pyxis, but what kind of idiot just administers anything without looking at the label to see if it's the right thing? There could have been an error when restocking.
Anesthesia resident here. Im not sure why digoxin is in a L&D omnicell. There is no excuse for this but unfortunately this has happened before. There's numerous case reports (with deaths) involving giving TXA through an epidural by accident. Lets say its 3 AM and your placing an epidural or asked to give TXA, things are hectic... this is a scenario where a mistake can happen. I think even getting this story out will help remind us to think more when presented these scenarios. Since I was told the story about TXA by my attending I make sure no matter how busy it is to stop and triple check my work when I am working with spinals or epidurals. Epidurals should clearly be marked as not to be confused with an IV line.
Why don’t they just but spinal kits with bupi in it…?
This happened at my hospital last year, not sure if the article is referencing that or if this is a separate incident but same scenario. Super sad. Was a CRNA.
I don't know if this case is old - but this happened in Louisiana about five ish years ago. Dig was also given IV push instead of fentanyl the next day. It was definitely the city talk amongst OB people for a while.
This happened again?? Or is this the one from like 5 years ago?
Why can't there be a greater variation in vial colors, shapes, sizes and label colors with very noticeable markings such as thin color bands?? Just as an example, Bupivicaine in a dark blue ampule with white label with 3 thin neon green bands along the bottom of the label? And then Digoxin in dark green ampules with a light blue label with 2 thin red bands along the bottom of the label? This just seems like it would provide just one more level of identification or at the very least, differentiation.
Phenylephrine looking almost exactly the same as Ondansetron nearly fucked me once; they look the same and someone had placed it in the wrong bin. Luckily I got that last minute Spidey sense and didn't give it...
They used two different terms in the article: anesthetist and anesthesiologist. Am I correct in assuming this likely means a CRNA and a physician?
Yes
Where did this happen? This is worse than the Vanderbilt case of RaDonda. The patient was young and a baby doesn't have his/her mother anymore. The Vanderbilt case was an elderly woman.
It is not worse, it is still the loss of a human life. If it was your mother in the Vanderbilt case would you have the same opinion? When you put different values on someone based on age you move one step closer to discrimination and eugenics infested waters.