AN ANESTHETIC DRUG ERROR - MINIMIZING THE RISK

A medication error caused a near fatal cardiac arrest in a previously healthy patient undergoing elective surgery. Inadvertent epinephrine i njection induced ventricular dysrhythmias, hypertension, hypotension a nd pulmonary oedema. The case was investigated using critical-incident technique and war; reviewed by the Risk Management Team of the Depart ment of Anaesthesia. The purpose of this report is to present the reco mmendations resulting from the investigation. These include: improved resident training in intravenous drug management, the use of anaesthet ic drug ampoules with distinct labels, and the development of a standa rdized colour code system for labels on anaesthetic drug ampoules. Fur thermore, it is recommended that all anaesthetic drug errors be report ed to the Canadian agencies responsible for drug packaging in order to identify patterns in anaesthetic drug errors, and to facilitate the i mplementation of effective drug identification systems.