You guessed it: plenty. Surgical teams administer the right medica-
tion to the right patient at the right time most of the time, but when
things go wrong, as they inevitably do, the consequences can be cata-
clysmic. I once investigated a case in which an 11-year-old boy died
because his anesthesiologist meant to give him ondansetron, but acci-
dentally gave him phenylephrine, a blood pressure-boosting drug,
because the similar-looking vials were next to each other in the anes-
thesia drug tray. Not only was it the wrong drug, but phenylephrine is
so concentrated that it requires a 100-fold dilution. The mistake
caused the child to have severe hypertension and a pulmonary hemor-
rhage. His young life ended the next day.
You need to eliminate the human factor in order to prevent such a
devastating mistake from happening on your watch. Unfortunately,
that's easier said than done.
Slip-ups and solutions
When we think about our typical procedures in the OR, it's easy to see
that we're asking for trouble. Consider the traditional old-fashioned
way of drawing up medications. If I need something, say morphine,
it's sitting in a drawer. If I plan to give it to my patient, I take an empty
syringe and needle and draw it out. Then I label it. Then I put it on my
anesthesia table, and when I want to give it to the patient, I reach for
it.
It sounds really simple, but it's not. The reason: I'm human and one
day, inevitably, I'll make a mistake. I'll pick up the wrong ampoule.
One that looks like morphine, but isn't. Even if I choose the right
drug, there's still a chance I'll put the wrong label on the syringe.
Why? I'm human, and humans make mistakes.
Or, let's say I manage to get the right drug in the syringe, and accu-
rately label it. It says morphine, and it is morphine. Unfortunately, I'm
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