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Medication vials
were unmarked on
the sterile field. The
surgeon injected 9-
year-old Ben Kolb
with what he thought
was lidocaine with
dilute epinephrine.
Unfortunately, sadly,
it was concentrated
1:1,000 epinephrine.
"When we started doing CPR and the child did not come right
back, I didn't feel a sense of panic, but a sense of dread," recalls
Dr. McLain. "It was very difficult to see a child die right before
your eyes."
Persistent problems
Don't think that devastating result could happen to you? Think again.
Here are medication issues I've seen repeatedly in ORs while consulting
with facilities for the Institute for Safe Medication Practices.
•
Labeling.
Clearly and completely label all medication containers and
syringes. A pair of anesthesia partners at a hospital didn't label drugs in
the sterile field because they had a system in place that involved drawing
certain drugs into specific-sized syringes. During a presentation about the
dangers of this practice, the anesthesiologists' faces turned white. They
both relied on the same system for identifying medication, but did so
with different medications. What would have happened if one of the part-
ners couldn't complete a case and the other had to step in? Labeling sys-
tems needs to be standardized so everyone's on the same page and care-
givers can provide safe patient care no matter which OR they step into
P A T I E N T S A F E T Y
SLEEP AID Always identify propofol, espe-
cially now that similar-looking medications
are becoming more popular in the OR.
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