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O C T O B E R 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
SAFETY
handed her a syringe, which the surgeon injected into the eye. When the
surgeon looked at the eye in the operating scope, she found that the
entire area was stained an opaque, dense blue.
Instead of VisionBlue, the tech had handed her methylene blue.
Despite multiple irrigations with saline, the eye remained opaque. The
patient was transferred to another facility for a possible corneal trans-
plant, but the outcome is unknown.
The nurse who handed the syringe to the surgical tech reportedly
thought the surgeon asked for methylene blue. Since the nurse couldn't
find the right receptacle on the table for methylene blue, she drew it up
into a syringe and handed it to the surgical tech, noting that all "you
need is a few drops" — which is true when you use methylene blue to
mark the location of the incision. The surgical tech incorrectly labeled
the syringe as VisionBlue before handing it to the surgeon.
This isn't the first time this has happened. An almost identical case in
North Carolina from almost 6 years ago just resulted in a $1.5 million
malpractice award. The patient was undergoing cataract surgery when
the ophthalmologist ordered VisionBlue to stain the capsule so the
cataract could be removed, and instead was given methylene blue.
Both the nurse and surgical tech testified that they announced methyl-
ene blue, but the surgeon apparently never heard that. The patient
became permanently blind and developed glaucoma in that eye.
Prevent the problem
So how do you stop such a mix-up from happening at your facility?
While it's important to have verification of the dye and labeling of the
syringe by 2 qualified personnel, this is about more than miscommuni-
cation. It's clear there is a system issue here.
The blues are a LASA (look-alike, sound-alike) drug pair. If your cen-
ter stocks both of these drugs, it's important to include these on your
