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Post by katevaughn on Aug 31, 2017 10:39:42 GMT -5
This month's journal club is presented by Faresha Sims. She chose a fantastic news article from The Seattle Times concerning a law suit filed over a medical error. It is going to stimulate great discussion and hopefully help us develop some safe habits that we can learn from each other to prevent errors like the one identified in the article. Enjoy! Here is a link to the article. The questions to be encompassed within your response: 1. Should anesthesia providers give IV drugs that are already drawn up by a previous provider? Do you know what that "clear medicine" is if you didn't draw it up? 2. If an anesthesia provider administers Zofran IVP or Sugammadex IVP at the end of a case and a patient becomes acutely and severely hemodynamically unstable and dies because the drug was actually vasopressin but was mistakenly prepared by the other provider who would be responsible for the medical error?
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Post by Mary SH CRNA on Aug 31, 2017 11:16:38 GMT -5
To err is human...what an unfortunate incident, worse so as it was avoidable--maybe.
There is really not enough information in this article to determine what or how it happened "died Nov. 23 after being injected with Chlorhexidine, a colorless antiseptic, during a procedure for a brain aneurysm." It's like a "click bait" article you would see on social media.
Should anesthesia providers give IV drugs that are already drawn up by a previous provider? If you don't trust your co-workers, you might want to seek employment elsewhere! That being said, I don't use anything left in draws and not from residents. Do you know what that "clear medicine" is if you didn't draw it up? Nope, you sure don't!
If an anesthesia provider administers Zofran IVP or Sugammadex IVP at the end of a case and a patient becomes acutely and severely hemodynamically unstable and dies because the drug was actually vasopressin but was mistakenly prepared by the other provider who would be responsible for the medical error? This is a worst case scenario! The stuff of nightmares. Yes, if you give it you are liable....however, the entire ship is going with you.
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Post by Kristen Horsman on Aug 31, 2017 11:50:08 GMT -5
1. My first instinct would say, you should not give any drugs drawn up by a previous provider. However, every day we hand off narcotics via EPIC trusting that the narcotic we are subsequently given is the correct drug in the correct concentration. As MSH stated, I would never give a drug that I found drawn up in the a drawer, but I think if you trust the CRNA that is handing off to you, there are instances where you can use meds previously drawn up by a colleague.
2. I believe both providers would be responsible. It would, however, be hard for the relief CRNA to prove the previous CRNA/resident had drawn up the medication.
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Post by Dahlia Rouchon on Aug 31, 2017 12:12:03 GMT -5
1a. Should we give drugs given up by prev. provider? Personally, I will give drugs given by another provider if labeled correctly (date, time, initialed, and discussed what's in the drawer on the cart) and within time prior to expiration. If to the contrary, I will dispose of the drug. 1b. We cannot know for sure if it is the drug as labeled unless it gives the expected response after given. 2. If a patient dies as a result of a mislabeled vasopressin drug for Zofran or sugammadex drug, who would be responsible? I think it could be multi-factorial but the hospital would be liable. I think the person who drew up the drug- if labeled incorrectly and the person administering the drug would be liable as well. Regardless, it is hoped that documentation and acceptance of the error would be made for discovery to prevent future systems errors from occurring.
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nanci
Junior Member
Posts: 57
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Post by nanci on Aug 31, 2017 15:43:32 GMT -5
1) No one knows what is actually drawn up by other providers. When I was in clinical as a SRNA I had an anesthesiologist take the syringe, look me in the eye and ask "DID YOU DRAW THIS UP?"- intimidating at the time but VERY CLEAR (Thank you Dr. Markus) that you do NOT use medications that you did not draw up yourself and/or trust what was given to you by another provider by verification. Agree with Dahlia that medications need to be clearly labeled correctly. If there is no time/date/initials on propofol left in the drawer by the resident I am relieving who stated they just drew it up- I throw it out.
2)If an anesthesia provider administers Zofran or Suggamadex at the end of a case and a patient becomes acutely and severely hemodynamically unstable and dies........OMG- I think definitely the person administering the medication would be liable. As for the person who drew it up incorrectly...may be more difficult to prove (after the fact, meds/vials discarded, syringe labeled?, a lot of variables). Could this be why we are supposed to save all vials until the end of each case here at Hopkins?
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Post by faresha on Sept 2, 2017 19:44:52 GMT -5
This was not a "click bait" article on social media. I was reading material from National Patient Safety Foundation (NPSF) and there were many pages of information pertaining to this. Instead of submitting a long article with many pages I asked the moderator, Kate Vaughn, if I could submit a nontraditional article and with her permission this article was submitted. There are many articles about this story with more details, just google if you need more info to feel that you know the whole story in order to discuss or learn from this mistake. Even if it was a "click bait" article from social media, a person died from a healthcare mistake so it shouldn't devalue the lesson that can be gleaned. It is a fact that a person died because a healthcare provider mistakenly injected chlorhexidine- an external cleaning solution- into a patient's body, that's not internet gossip. It's obvious that chlorhexidine like betadine are not meant to be injected into people. Because chlorhexidine is clear, it can be mistaken for that "clear medicine" that one is assuming that (s)he is injecting. That "clear medicine" may or may not be what you think it is and despite differences of opinions...that's a serious matter. Serious enough for me to take an additional few seconds and draw up my own drugs.
I learned in my bachelors of nursing (BSN) program that nurses should not give drugs that they did not draw up or did not witness being drawn up. I do not give any drug that I did not draw up or witness being drawn up except the handoff of narcotics. To err is human so I try to decrease the risk of err by knowing that the mere fact that people are human means that we are all capable of making errors.
If there are other anesthesia providers that do not choose to give drugs that you did not draw up, I disagree that this suggests you don't trust your coworkers and should consider seeking employment elsewhere. I have no intentions of changing my practice or place of employment to conform to social or cultural norms at the risk of lowering my standards while providing patient care. I reject statements that suggest providers do not belong or fit into a certain type of workplace because they don't adhere to cultural norms. These sort of statements and attitudes are barriers to the culture of safety. It is a fact that you do not know what you are injecting if you did not draw up the drug or witness it being drawn up. Mindfulness and vigilance are good attributes for anesthesia provides to have. We all have individualized practices and we should hold ourselves accountable for what we deem our best practice and not feel the need to prove that we "trust" anyone by injecting a drug that we have no idea of what it is just to prove "trust" of another human especially since it is known that "To err is human..."
Worst case scenarios are in the eyes of the beholder. Death is not the only worst case scenario. I read of a situation where a patient was injected with a syringe contaminated from another patient. Took the anti-viral drugs, as a result had liver failure and needed a liver transplant, and for years had complications from this medical error. All of this happened a few months after she gave birth to her first child and she said that she wished she had died than to have to live her life like this which made her incapable of enjoying her child and family.
In my practice, I am less concerned about "the entire ship going with" me and more concerned about educating myself on the errors of others and learning from them so that I can hopefully be as safe as possible when patients are trusting me to do what I consider best for them.
1. No. No. 2. The person giving the drug is responsible for ensuring what (s)he gives.
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Post by AugustineEmmanuel on Sept 3, 2017 9:33:42 GMT -5
This is an interesting read. Ideally we would all like to say that we should never trust the accuracy of any drug unless actually drawn up by us, however in real life we often take over cases where drugs have been prepared. We assume a certain level of accuracy and trust in the person who's passing the drugs over to us. I think that in the vasopression/ondansertron scenario, in my mind both providers would be liable however legally I'm unsure of the answer who would be responsible.
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Post by faresha on Sept 3, 2017 15:57:21 GMT -5
Augustine post is my favorite thus far. Yes, there is a difference in what we know to do and what we practice. It's been researched and called normalization of deviance. The purpose of my article was to raise the thought of should we consider changing the cultural norm on this. For example, why does anesthesia culture promote the behavior of the previous provider drawing up drugs only to hand them off. For example, providers come to take over a case and say...have you drawn up the zofran and reversal. Response...no because I won't be here to give it. When providers hand over anything but narcotics to me I tell them that it is so unfortunate that those drugs will be wasted because I don't give anything that I didn't draw up and I encourage them to not feel obligated to draw up all the drugs for a case at the start if they know they will not finish the case. It's clearly a cultural norm to draw up non-emergent drugs that one will not administer. There is no meaningful purpose for this and I shared this article to propose that this can possibly cause more harm than good and it is a serious matter to know what that "clear medicine" is prior to injecting it.
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Post by Mary SH CRNA on Sept 4, 2017 17:19:41 GMT -5
Faresha,
You appear to have taken offense to my post. So sorry, not my intention! Discussion boards are hard as you can't see facial expressions or verbal connotations and some are more readily offended than others. My apologies. I actually like click bait at times--except when I have to click "next" 25 times to get through the story! The media is instrumental in pushing change in healthcare. Josie King and Dr. Nikita Levy are some famous (infamous) cases involving JHH that played out in the media.
Open dialogue in a forum such as this allows people to freely express their opinions; we don't all have to agree. As for this particular subject, there is no "right" answer...which is why it should be fun to discuss.
Regards, Mary
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Post by Belinda Gardner on Sept 5, 2017 11:02:20 GMT -5
At this institution the pharmacy has most of our anesthetic medication pre-drawn up for us unlike others where you need to draw everything up yourself which likely reduces our risks of medication errors. Since we set up for our own cases this is not so much of a concern except with case handoffs or when we help each other set up for cases as in emergencies. I just wonder: how the heck do you draw up Chlorhexidine! I digress, anyway... If you give it, you are most likely responsible. To truly know what you are giving you need have drawn it up yourself or watch it being drawn up. I think that all of us would throw anything out that we didn't draw up and put in the drawer ourselves or had any questions about. Also, drawing up vial medications as they are needed is probably safest.
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Post by faresha on Sept 5, 2017 12:05:55 GMT -5
Hi Belinda. To my understanding from reading various resources on this, there were 2-3 basins of "clear" stuff setup to be used on the patient. Apparently, the basins got mixed up and it's apparent that the person who gave the "clear medicine" didn't realize that it was not what was expected but instead chlorhexidine. When Chlorhexidine is not in a prep stick, it appears clear and of similar consistency as saline or medication. It sounds outrageous but I can totally see how a mix up like this could happen if the cleaning solution looks identical to the medication/saline and they are both in close proximity. Medication errors happen even when drugs don't look alike so I'm not shocked that this could happen.
I agree that drawing up meds as needed is probably safest; and likely decrease cost by decreasing drug wastage. If someone takes over a case but the plans change and patient remains intubated but 2 vials of Sugammadex is already drawn up...money wasted.
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Post by Vania Milnes on Sept 8, 2017 9:55:03 GMT -5
1.) I do not tend to give drugs drawn up by another provider unless it is a narcotic and the individual has clearly labeled the medication. Anything unlabeled clearly in the drawer I throw away. It is helpful that most of us pediatric CRNA's save our vials until the end of the case, and although this isn't foolproof, it's nice to see exactly what has been drawn up. If I'm taking over a case and the provider happens to have drawn up reversal or Zofran or something and the empty vial is sitting right there I feel much better.
I insist that the students I precept also do this and show me what they've drawn up before giving it to the patient. We had an incident in peds where the surgeon administered Bupivicaine of a wrong concentration to an infant and the ONLY way it was discovered is because the nurse that was covering for the circulating RN for a break happened to notice the vial sitting on the nurse's desk and said something (after injection of course). Thankfully the patient was ok, but required a prolonged stay and an uncomfortable conversation with the parents. I definitely save ALL of my vials since then!
A "clear" drug can be a million different drugs!
2.) I believe that unfortunately both providers should be liable. It doesn't seem completely fair to the person that administered the drug, but this situation is so sad and I don't know that there is any way to lay blame on one individual. That being said, drawing up drugs as you need them appears to be the safest bet... And I agree with you Belinda, HOW IN THE WORLD??
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Post by darolyn on Sept 8, 2017 10:05:06 GMT -5
I am not in favor of giving drugs drawn up by another anesthesia provider....even if it is labeled, I can not say for certain that drug is what it purports to be.
If a medication is admin'd by me and the patient has a critical or fatal reaction, it would seem that the sole liability would be mine. But I would definitely hold the other provider accountable.
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Post by Emmanuel Ibhaze on Sept 10, 2017 11:43:39 GMT -5
I totally agree with Belinda that drawing up vial medications as needed is the safest practice. It baffles me why some providers draw up a few syringes of Zofran at the beginning of the day because they have a few scheduled cases in their room. Really, how much time does it take to draw up Zofran, Ketorolac, or any medication at the end of a case? Reading through the posts it appears most of us waste what we did not draw up. My guess is patients' are not billed for these wastes and I wonder who bear the costs. I think the lesson here is to draw up vial medications as needed. It ensures patients' safety and reduce waste.
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Post by mdougla5 on Sept 10, 2017 16:43:45 GMT -5
1. As a general rule, I do not use syringes that were drawn by another provider. This practice ensures my own accountability in managing the cases, more than me not trusting the professionalism of a peer.
2. If I gave a medication that was mistakenly prepared by another provider, the owness would be on myself. When I take over a case, I make it my responsibility to ensure that all aspects of managing the case are managed optimally under my supervision. Therefore, if I have to waste medications that were already drawn by another provider, I do so without hesitation.
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