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Post by Soo-Ok Kim on Sept 11, 2017 12:05:55 GMT -5
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?
Although I understand the point not to use predrawn drugs by other providers, we practice medicine where multiple handoffs, shift work, and multidisciplinary professionals involved. So, we have to develop the system to ensure safe, efficient, and not so much wasteful practice during hand off. I totally agree with Emmanuel drawing the drugs when you need to give it to decrease mistake and waste. Also, I only prepare for the case in the room, not for the whole day and do not leave any extra drugs available in the cart. This way, there is less chance to grab wrong drugs by anyone by accidnet. I selectively use predrawn drugs based on how that was communicated to me and/or who I am getting drugs from. Generally speaking, if I found the predrawn drugs in the drawer without any clear communication, I threw them away.
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? Legally, the person who administered the drug is responsible for the event. This can happen to anyone even when the person who draw the drug and who administer it is the same. There was one incident I remember is that rocuronium was given instead of metoprolol at the end of the case on LMA/GA. That created unnecessary stroke diagnostic tests until someone identified the cause of delayed emergence. Soo-Ok
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Post by faresha on Sept 11, 2017 20:57:41 GMT -5
Emmanuel, That's exactly why I chose this topic to hopeful cause more of us to ask the question of why do we do what we do and does it serve a purpose and is that purpose helpful or potentially harmful. I'm sure Terry English wouldn't mind me sharing a conversation he and I had over a year ago. It made me think twice about my wastage of in the OR. Terry and I were talking and he had just returned from a mission trip. He told me that it's difficult for him to see us waste so many drugs yet when he's on a mission trip he imagines how desperately he wishes he had just 1-2 vials of certain drugs because in that area 1-2 vials of what we waste daily is sacred in other places.
Emmanuel, Darolyn, Vania, and Monica, I just can not wrap my head around any legitimate reason why another provider should draw up drugs knowing they will not give them. Most of us all know of a situation where a medication error occurred. It happens! So, I am just not comfortable giving a drug that I did not draw up or witness being drawn up.
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Post by Ben Waldbaum on Sept 13, 2017 13:01:33 GMT -5
I think many providers prefer to draw up their own medications, and while it is clearly wasteful, providers typically choose the "safe" route when there is even a shred of doubt. The example in the article does not clearly say how the mistake happened and whether it involved more than a single provider or transfer of care.
I think this question can only be answered by an attorney, but based on some of the widely known criteria for malpractice I would argue that the 1st provider sabotaged the 2nd provider. There is no standard of care to discard medications that are labeled correctly so it would be hard to argue that the 2nd provider did not meet the standard of care. Is it wrong for the 2nd provider to assume the 1st provider labeled a medication correctly? I don't know how one could answer anything but no. When a patient is in the ICU, and the nurse gives report to the next nurse, are all the infusions to be discarded? If pharmacy prepares a medication and labels it incorrectly, is the nurse who administered it liable? Medical malpractice requires that there also be negligence, which in this care was clearly the 1st provider who incorrectly labeled the medication. I do not believe the 2nd provider would have any liability in this case.
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Post by chrisdiem on Sept 13, 2017 13:33:58 GMT -5
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? -As other have stated in my practice do not routinely administer drugs that I have not drawn up myself. However, just like most things in life there are exceptions to this. When taking over cases we routinely hand over partially used syringes of propofol, muscle relaxant, narcotics etc that were drawn up and have been administered by another provider. In these situations I look for appropriate labeling of syringes as well as the empty vials on the anesthesia cart which provides me with some degree of confidence as well as the fact that these particular medications have been administered throughout the case without adverse event. If I ever have any question regarding the authenticity of any drug I will discard it and then draw it up myself. As Vania mentioned many providers including myself do not draw up medications until we are ready to administer them. How long does it truly take to draw up zofran and sugammadex at the end of a case.
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? -There is actually a fictional book which touches on this topic called Oxygen by Carol Cassella. In the book a pediatric anesthesiologist loses a patient and it turns out that one of her colleagues who was diverting narcotics changed a narcotics syringe for an adrenergic antagonist while giving a break and well bad things happened. Although this is a fictional story this is something that could potentially happen in our practice. I would think that both parties would have some degree of liability over the issue however as someone else had mentioned it would be hard to prove misconduct on the person who drew up the drug as it would most likely be a he said she said situation. So unfortunately I think that the majority of the responsibility would likely fall onto the individual who administered the medication.
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Post by Wai-Ling Lo on Sept 15, 2017 8:47:39 GMT -5
1. Do you know what that "clear medicine" is if you didn't draw it up?
No. Should anesthesia providers give IV drugs that are already drawn up by a previous provider?
Ideally no. But like everyone says, we often found ourselves doing it.
One time my student mistakenly used the metronidazole bag as the NS flush bag to reconstitute medications. Lucky that I caught it and we discarded the meds, no harm was done. I really don't know what drug is that clear solution when it is prepared by others (or sometimes even by ourselves if we get distracted). Med errors can be contributed by so many factors, we just have to be prudent and stay vigilant at all times. I don't hesitate to waste or discard any meds that I have any doubt(especially those epi 10mcg bag prepared by others...).
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?
The one that administered the drug would be responsible.
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Rico Liwanagan CRNA
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Post by Rico Liwanagan CRNA on Sept 15, 2017 9:24:23 GMT -5
1. Should anesthesia providers give IV drugs that are already drawn up by a previous provider?
Unless it's a narcotic that are properly labelled, i toss it to the sharps container. Training, education, & instinct tells me that I should not give any medication I did not draw up. Exception will be meds that are pre-drawn by pharmacy and are properly labelled anyway. Nobody wants to be in a situation or scenario that you are not sure what you actually gave, right? It may be wasteful? Yes, but it's safer to the patient? We, CRNA's, are the Air Marshall in the OR. Safe & Vigilant anesthesia care for all our patients should be our #1 priority.
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?
Theoretically, I believe both CRNA will be negligent. However, the original CRNA assigned to the patient who prepared the medication may argue & have a good alibi that he/she have thoroughly endorsed care to the relief CRNA at a certain time & endorsed the meds as well. Beyond that time the accountability of patient care falls to the relief CRNA. And in the court of law, the attorney will ask if it is standard practice for a CRNA to administer a medication for which he/she did not prepare? And the answer is NO, it's not our standard of practice! And so since the plaintiff (relief CRNA) who administered the medication did not follow standards of practice. Then he/she was negligent & will be responsible for the medical error.
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Post by klinden on Sept 15, 2017 21:10:18 GMT -5
1. Should anesthesia providers give IV drugs drawn up by a previous provider? It's interesting that most posts say they won't give a drug drawn up by another provider and yet in the OR we routinely do. we are fortunate at our institution in that most of our drugs are provided by the pharmacy leaving only a few drugs like narcotics to be drawn up. Very few providers actually draw up their drugs correctly so unless they are "in line" I won't use them.
2. Who's responsible for a drug error ? If the drug is labeled correctly - date, time, etc the provider who drew up the drug would be responsible. This would only be discoverable after examination of all syringes, supplies gathered at the end the resuscitation. Seldom happens - too much confusion.
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Post by faraclarke on Sept 18, 2017 17:17:02 GMT -5
1. I agree with others that I do not routinely give medications that I did not draw up myself. There are, however, instances in which I have taken over a room or just received report for a break and the patient instantly moves (despite reporting that the patient was paralyzed). And in some of those cases the previous provider did not have any paralytic or fast-acting sedative drawn up. I believe that whether it goes to waste or not, in my practice, I always have an extra syringe of Propofol or patient-specific induction agent ready to administer in case the patient moves for whatever reason. I am very appreciative when another provider has meds already drawn that I can quickly grab and push, as movement can be detrimental in some cases. I find that in an urgent case I would rather "trust" the syringe, although this is not the ideal. And as we all know, it doesn't matter to anyone else in the room that you just got report and there was no Propofol drawn up- you are liable and responsible. My experience has changed my practice such that I check for "something to push" when I get report and if there is not anything I draw something up immediately.
2. In the case of Zofran and Vasopressin, this is horrible. I am surprised that so many patients come into the hospital calm and trusting. People literally trust us with their lives; they are unconscious, vulnerable, and most of the time are blindly trusting us to speak about them with respect, protect their integrity, do as we say we will do, put them to sleep, keep them alive, and wake them up so that they leave the hospital at their baseline. It is so easy to forget that we hold the lives of every single one of our patients in our hands because things easily become routine and it is easy to take a routine case for granted. Every decision we make, every medication we give, every intervention we perform has the potential to help or harm, and it could change the patient's life forever. Personally, I would feel and be 100% responsible if I gave a medication that I did not draw up that resulted in the harm or death of a patient. The provider who drew up the medication is responsible as well. I know that cases such as these happen and it is detrimental and it is our responsibility as the "gatekeepers" to ensure that we do all that we can to protect our patients from harm.
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Post by jhadley on Sept 19, 2017 11:38:21 GMT -5
I think several great points have been brought up so far. In response to question 1, I have given medications that have been drawn up by previous providers if they are properly labeled, dated, and timed. I also look through the open vials if they have been saved to ensure there aren't any outliers. After reading this discussion and article though, I feel it may be time to adjust my practice as the point was made that all clear medications look alike. Medication errors are common and there are plenty of distractions in the OR that could lead to mistakes even in seasoned providers. In my practice, I have shifted from the SRNA mentality of having to be completely ready by drawing up every medication possibly needed at the beginning of the case to a draw it up as I need it practice. I feel this is the safest and most cost effective strategy, so if I am relieved at least there is no question and drugs aren't wasted. Maybe this is what we should be teaching our SRNA's and possibly the residents too.
In response to question 2, I would think legally both parties could be held liable, however professionally I would feel ultimately responsible since I was the one who administered the drug and caused harm to the patient.
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Post by Kim Hall on Sept 19, 2017 11:42:21 GMT -5
1.For the most part I give medications drawn up by other providers that are correctly labeled. I may be naïve as a new provider or simply use to the team dynamic of more than one provider being involved in a case.
2. I think both providers should be liable on some level. I agree it is best to just draw up the medication when it is needed to reduce the likelihood of this type of error.
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Post by krechti1 on Sept 20, 2017 8:56:25 GMT -5
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?
In a perfect world, we would always draw up our own drugs just before giving them. However, in the real world, there are instances where we draw up drugs, label them, and save them for later use. I take this on a case by case basis. I would never give a drug I find in a locked drawer when I don't know who prepared it. However, if I am giving a break and somebody has labeled drugs plugged into the IV line, or narcs which they have used a portion of, I will administer these drugs after receiving report. Same for case handoff. With that said, I never draw up non-emergent drugs such as toradol and Zofran until I am ready to give them. I also agree that keeping the vials is helpful. In general, using common sense and knowing the person handing off to you affects my decision to use pre-drawn up drugs.
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?
The provider who gives the drug is ultimately responsible.
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kty67
New Member
Posts: 22
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Post by kty67 on Sept 20, 2017 10:26:33 GMT -5
1. yes we should trust other providers and we do it every day when somebody relief us. But few thing we do already to protect ourselves and following provider: leave used medication vials until the end of the case. I always leave vials except propofol (it is different from other meds). 2.Leave Zofran in a vial until you ready to give, there is no reason to draw it ahead of time, same with Sugamedex. I try to draw most of my meds right before I give it, so I have vial in my hand. I don't even like when some providers pull out reversal syringes during the case, I feel like it is available when needed, and if it is not on top less likely you use it by mistake.
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Kristen Praesel Lang
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Post by Kristen Praesel Lang on Sept 20, 2017 13:13:22 GMT -5
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?
I do not give IV drugs that have previously been drawn up and left in a drawer. There is no clear way to know what the “clear medicine” is if you did not draw it up. That being said, I will administer IV drugs that were drawn up by a previous provider given there is some form of handoff /communication involved. For instance, when giving a break or relieving another provider you take over an existing case or start the next case. In relieving on an existing case, you use the same drugs (narcs and paralytics) that the provider has out for that patient. In starting a new case, the provider you relieving will frequently say something like everything in the top drawer is clean and ready to go. Most oftentimes, I trust the provider I am relieving. Consistent with what the provider communicated, these drugs should also appear clean, as well as appropriately labeled, timed, and dated.
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?
All providers involved in the preparation and administration of the mislabeled drug would liable as well as the health system.
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Post by emedina1 on Sept 28, 2017 20:56:07 GMT -5
I will only give pre-drawn drugs if it is handed to me by a co-league labeled and dated. ( this is to say the co-league I k now well) I can not take chance.
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Post by Meginnis on Sept 30, 2017 12:02:33 GMT -5
I will usually take the narcotics that are signed over in a case. I prepare my drugs as I need them to avoid waste and I typically throw away the Zofran, antibiotics, epi bags, etc. that are found in many carts. I would think that whoever pushes the incorrect drug would be the provider held responsible. Although Docs push drugs all day that they didn't prepare, but I guess the difference is that we are standing right there! When in doubt throw it out!
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