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B
y all appearances, it was another busy vascular case
involving numerous insertions of embolectomy catheters
and injections of contrast dye. However, the physician
assistant who typically worked alongside the surgeon
was tied up in another room, so the surgical tech
stepped in to help while also performing her regular duties. During
the procedure, she turned to draw up contrast dye, but instead filled
the syringe with a local anesthetic. Luckily, she realized her error
6 Lessons Our (Near Miss)
Medication Error Taught Us
Catherine Dutton, MSN, RN, CNOR, and
Diane Betti, MSN, RN, CNOR, CSPDT, ST
Springfield, Mass.
Injecting a patient with local anesthetic
instead of contrast dye was a blessing in disguise.
• HARD STOP After our near miss, we decided
to store local anesthetics in lidded specimen cups.
Catherine
Dutton,
MSN,
RN,
CNOR
