SALINE FLUSH LEADS TO ACUTE PARALYSIS OF AN AWAKE PATIENT ROBERT SCOTT KRISS, DO
Case Study 3:
SALINE FLUSH LEADS TO ACUTE
PARALYSIS OF AN AWAKE PATIENT
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CASE SUMMARY (½)
The Patient:
•
48-year-old man with colon cancer.
•
In for laparotomy (surgical cut into abdominal cavity) & sigmoid colectomy (removal of last
What Happened:
•
An IV cannula (inserted in the arm or hand) was
inserted for pre-op fluids.
•
The Anesthesiology resident assigned to the
case flushed the patient’s IV cannula to ensure it was section of colon).
functional.
•
The Anesthesiology department had run out of bright red labels for rocuronium (a strong muscle relaxant).
Presentation title
CASE SUMMARY (2/2)
•
Syringes containing rocuronium were labelled with handwritten labels.
•
Immediately after IV flush with a syringe labelled as “0.9% saline”, the patient became unresponsive & immobile.
•
The patient was then intubated, the operation was cancelled, and the patient was transferred to the ICU both ventilated & sedated.
•
After an hour in the ICU & muscle relaxant reversal medication was given, the patient was extubated & stable.
•
The patient was scheduled for close follow-ups to assess potential complication both physically & psychologically
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COMPROMISED QUALITY OF CARE ADVERSE DRUG EVENT DUE TO A MISLABELING
SYRINGE SWAP.
THE PATIENT’S SURGERY WAS DELAYED DUE THE INCIDENT.
THE PATIENT RECALLS FEELING “PARALYZED” UPON RECEIVING IV FLUIDS.
POTENTIAL FOR PTSD, SEVERE ANXIETY, &
OTHER PSYCHOLOGICAL
ISSUES.
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What could be done differently
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FUTURE PREVENTION
•
Preprinting labels and color-coding systems
•
Enhancing education and training on
medication safety for all healthcare providers
•
Introduction of barcode or QR code systems for
medication verification before administration
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CURRENT MEASURES
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ACTIONS
RECOMMENDED
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• Strict adherence to pre-printed labels
• Implement color designated labels
• Use bar codes or QR codes on printed
labels
• Never combine syringes prior to labeling
THANK
YOU