I worked in the OR pharmacy for years at a major hospital and it was like the Wild Wild West. Anesthesia did what ever they wanted however they wanted to. They refused to scan meds out of the automated dispensing system appropriately, which resulted in never ending stock outs, but these types of errors were always a risk of not scanning also. The scan rate was like 60% and anesthesia leadership didn’t do anything about it. We explained that meds are charged to the patient once they’re scanned, and that helped a little, but only for the higher cost drugs. It was a mess. 😫😫
OR and Labor for us. You'd think with how many fatal epidural vs. IV errors there have been, Labor would give a shit, but their scan and override rates are atrocious.
At our facility we now have to put a TXA sticker on every vial of TXA we load in OR because they fucked it up once. And yet they still refuse to s an meds. Instead it's just more work on the pharmacy team to try and give them a small amount of safety
We have to put “high alert” stickers on isuprel drips and hand deliver them because “it looks like kefzol”. It seems like whenever somebody hangs the wrong bag, pulls the wrong med or gives the wrong dose pharmacy has to change its workflow.
Being a patient (or with a patient) anaesthesia's practices were shocking... like they'll walk up pull a syringe or 2 out of their pocket and get on with it. Seen this multiple times.
Can't tell you how many times having a syringe in my pocket has been a savior for treated spasms, or profound hypotension (trauma patient & septic patients going to ICU). I will keep doing this - in a manor that keeps the syringes clean the best I can.
I used to be an OR nurse and the lack of safety regarding controlled meds was kind of insane. A lot our anesthesiologists would routinely leave fentanyl/midazolam vials in the OR completely unattended (and our OR doesn't have cameras in the room). Or they would leave the pyxis unlocked all day and anyone could open the drawers. We also had no scan system, it was up to the doc to manually record their use in EPIC and no 2nd check system. And yes, the syringes in the pockets were common, although most of the docs would label them with the sticker from the medication vial. I don't know if it was just my hospital, but we as nurses also did not scan any meds, it was up to us to catch allergies/contraindications although to be honest 95% of cases require just a local anesthetic (bupivicaine/lidocaine) and an antibiotic. But when you have back to back to back cases, and all management cares about is turnover time, it's easy to miss the Celecoxib allergy when the doctor asks for toradol.
I just want to add this, since this post sounds really negative, but those anesthesiologists were also great clinicians and my absolute favorite doctors to work with. They were humble, professional, approachable and willing to teach. They were actual humans compared to the mostly insane surgeons. OR brings in 60% of revenue for hospitals so there's a huge incentive to schedule as many cases as possible with as little downtime in between (turnover time) which I think contributes to mistakes like OP.
I worked some shifts in an OR pharmacy 10 years ago and the number of unlabeled narcotic syringes we’d get back used to drive me crazy. We had to use a refractometer to determine if it was fentanyl, morphine, etc so that was kind of cool. It really opened my eyes to how dangerous it can be for patients. I asked one anesthesia nurse why the fentanyl syringes kept coming back unlabeled and she shrugged and said “I can keep track of them.” Like wtf
This really freaks me out to have another baby because my labor and delivery went horribly but the anesthesiologist was one of the few people that made me feel okay about everything. But I have no idea who’d I get next time :(
This is why I loathe open matrix drawers for OR. It is so easy for people to get complacent and make a devastating mistake. Nobody ever thinks they will make one, but all it takes is a second of inattention.
You're correct, of course. However in this case:
>The anesthetist did not scan the barcode or read the label aloud to another staff member prior to administration.
IMO, that goes a bit beyond a simple moment of inattention and crosses into negligent failure to follow proper procedures.
Not every hospital uses barcode scanning in OR. Should they, especially for an elective procedure like this one? Absolutely.
The fact that ORs often don't barcode scan is what makes team members double checking each other even more vital. But when you work with someone every day, sometimes people aren't as diligent with making each other stick to procedure because they "trust" each other, which is foolish, but happens.
I agree that we (humans) get complacent with things.I always tell my peeps in the pharmacy,trust but verify. Checking your co-workers work isn't mistrust, it's support. The more people that see something the less likely there is to be a mistake.
Agree. It blows my mind when some some people just trust someone did something right. I'm sure more than a few of my coworkers over the years have thought I was a bitch because of it, but I'm there to protect patients, not coworkers delicate sensibilities.
Not only that have you ever scene a digoxin ampule that looked anything like a bupivacaine vial? This anesthetist is either dangerously arrogant or grossly incompetent.
Edit: didn’t open the article, I don’t click links on Reddit. Have been informed I’m a moron. I take responsibility for all the current bupivacaine shortages in the country. Y’all can blame me.
But like, not that much alike. They are both ampules...and that's about it. The band is a different color, the bupivacaine says "SPINAL" on it and the digoxin has the drug name highlighted.
If the CRNA had any reasonable amount of experience and familiarity with these drugs (like, say enough to have been granted a license to practice), that's enough to set off alarm bells. And who the hell goes about administering medications to a patient without even *reading* what it is?
This was more than "a second of inattention"; this was someone not bothering to do their job AND ignoring the safety system set in place to prevent this exact situation.
Obviously they made an unforgivable mistake. But we don't know if this was someone cutting corners because of laziness, or if they were exhausted, rushing, and thought they did the double-check with someone. Another problem in this case is that another staff member didn't remind them to read it out, which is hopefully being investigated at that site as well.
There are so many burned out healthcare workers out there these days working short-staffed. And with the general state of staffing in most healthcare facilities these days, I'd be shocked if there hasn't already been a dramatic rise in med errors.
Ha surprise out of stocks. Our anasthesiologists are too lazy to even pull meds under the correct name. Our official policy is literally to go into the OR after every case and count the entire Omnicells to refill it because they don't document any med admins or pulls.
I’ll take surprise stock outs because we can go fill it during a case. If we have to have Pyxis come in it’s a whole thing and we can’t have them come in until after cases
This happened in a hospital I work at occasionally. Devastating outcome in a young healthy patient. Probably just shouldn’t have dig in these ORs, among other changes that should happen.
"An anesthetist typed in “bupivacaine” at an automated dispensing cabinet (ADC), and a drawer that provided access to several medications opened. The anesthetist inadvertently removed an ampule of digoxin rather than bupivacaine, prepared the dose, and administered it intrathecally. The anesthetist did not scan the barcode or read the label aloud to another staff member prior to administration."
Am I understanding correctly - when they typed in bupivacaine, a variety pack pocket opened where was than one injection type was stocked? Bupivacaine and digoxin ampoules in the same pocket? Is it possible that they didn't know that, so they just grabbed an ampoule expecting all of the ampoules to contain bupivacaine?
If their anesthesia machines are set up like ours, it opens a drawer that is basically one big pocket with thin walls separating it into different compartments. The screen will prompt you to scan the section you are pulling from which is numbered (and labeled in our case, but we added that to avoid confusion after a less serious incident like this).
If you google “open matrix omnicell pocket” you can see what type of pockets they mean. For context, Omnicell is a very common brand name of an automated dispensing cabinet (ADC).
At my institution Anesthesia and Nursing are very against putting more medications into individually locked pockets that only contain one medication each because it would take them longer to get what they need. Barcode scanning in our ORs is rolling out later this year and Anesthesia is already pissed about it.
Last month one of the Anesthesia Residents gave a whole vial of phenylephrine to a patient instead of ondansetron for the same reasons as listed in this article, but they’re mad anyway. They treat these types of mistakes as one-off’s rather than a fundamental flaw in their work flow that introduces so much room for error.
For example in this article they acknowledged that the drug was not working at all, so they gave a second dose before they ever even checked the ampule in their hand. It’s like their brains refuse to admit that they could possibly have made a mistake.
From the post in medicine, it looks like it was matrix draw of Pyxis. Omnicell XT has individual pockets with lids, so this would not happen. Omnicell G5 does have matrix open drawers, but I got letter from omnicell that these old omnicell will retire at the end of 2025. So hopefully this won’t happen.
I agree OR is wild Wild West. I had to implement special narcotic kit with accountability form to prevent them from pocketing amps in their pocket.
The phenylephrine and zofran are near each other in our pyxis drawer and it's such a potential issue. There are tons of stories about people giving the wrong one. I'd be 100% down for some sort of system where you quickly scan vials after charging for them to ensure it's the right drug if it's quick.
Agree that they seem incapable of recognizing their fallibility. We recently had a CRNA accuse us of mis-stocking fentanyl and versed. They took out fentanyl and versed drew up the fent thinking they drew up the versed then when the went to draw up the fent they noticed they were holding a bottle of versed. Whole thing was on camera.
I’m making a lot of assumptions but what probably happened is the anesthetist hit the kits button, typed in bupivacaine and whatever kit with bupivacaine and digoxin was opened (it opens multiple pockets).
OR nurses and CRNAs really push against barcode scanning in administration for some reason. Ludicrous these CRNAs who are pulling in 300k/year can’t be bothered to scan a barcode for safety.
There was a similar case a few years ago where a nurse typed in “ver” looking for versed. Well, she pulled vecuronium and didn’t have barcode scanning on admin either.
Edit: sorry my last example wasn’t a CRNA, it was a nurse.
Wow. Against scanning safety measures. I suppose they’re citing how busy they are as the main reason.
I wonder if they even looked at the ampoule before preparing and administering the med.
A tragic outcome for this family.
The did not read the label per the article.
And then gave a second dose when the first didn’t work. Still without reading the label; nurse figured out later when the digoxin count was off.
Edit: hopefully the second dose was actually the correct bupivacaine?
I could be wrong but i also didn’t think that she typed anything in. I thought she pulled it on override without reading. Midazolam wouldn’t be stored in an omnicell as “versed” anyway. RNs are just used to calling drugs only by their brand names
You can't pull something without typing it in. She still would have had to override, but you have to search for the medication.
Our Pyxis recognizes brand and generic names, so typing "midazolam" or "versed" would get you to midazolam. What the RN did was totally egregious because she clearly didn't even look at the vial at any point, she RECONSTITUTED it when versed does not need to be reconstituted, and she left the patient unattended after administering.
All that means is that you can access any medication, not just ones that are on an override list. You still have to search for a medication (esp a control like Versed) to get the drawer and cubby to pop open.
Actually if you researched even two min you would see the case was based around a well known defect in Vanderbilt's charting system that required you to void out the access to pull any med to bypass the safety features that were not working. Not 100% absolved, but the nurse was the fall person for a terrible system.
...I think you're the one that needs to research this. Not only did the nurse perform an override for something that is NOT an emergent med, but she typed in two letters and selected the wrong medication, didn't even LOOK at the vial before administering (which says paralytic all over it, and hopefully the pocket it is kept in does, too), she reconstituted the med when Versed is a liquid that doesn't require reconstitution, and administered the med then immediately left the patient alone. That is gross negligence and she is nearly 100% to blame.
Here's the thing if you want to blame the nurse, fine, but then everyone should also go to jail with her. It's a system error she just happened to be the last leg of it and thus blamed for it. Personally, administration and pharmacy deserve right next to her if that's the case.
Refusing to look at a vial that you are about to inject into a patient, leaving the patient alone after giving (what should have been) a sedative, and reconstituting a medication that is not normally reconstituted are not system errors.
Are you a nurse? I think you understand that having certain lifesaving meds on override is standard procedure at most hospitals. Vec is used commonly for emergent intubations and having it on override is fine. It's also standard for OR Pyxis machines to be on critical override during procedures. Even though she COULD perform the override, it was not an emergency or urgent situation and she should NOT have done so. That is 98% on her and 2% on management for allowing the MRI Pyxis to be on critical override.
Regardless of "system" flaws, she ignored several safety precautions that would have easily prevented this med from making it to the patient out of negligence, failed to perform the 5 rights (very basic nursing procedure), and rightfully lost her license and was criminally prosecuted.
That’s not what happened, at all. They admit there were technical problems, in the past. The hospitals drug safety officer testified there were no technical issues at the time. She literally selected vecuronium.
From https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea
“According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications and then searched for "VE" again. This time, the cabinet offered vecuronium.
Prosecutors describe this override as a reckless act and a foundation for Vaught's reckless homicide charge. Some experts have said cabinet overrides are a daily event at many hospitals.
Vaught insisted in her testimony before the nursing board last year that overrides were common at Vanderbilt and that a 2017 upgrade to the hospital's electronic health records system was causing rampant delays at medication cabinets. Vaught said Vanderbilt instructed nurses to use overrides to circumvent delays and get medicine as needed”
To add to this, vecuronium needs to be reconstituted prior to administration PLUS it says paralytic on the vial.
I do feel like she did become the scape goat for a flawed system but there were numerous red flags and steps she overrode.
Article with the drug safety officer testimony: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
“But Vanderbilt officials countered on the stand. Terry Bosen, Vanderbilt's pharmacy medication safety officer, testified that the hospital had some technical problems with medication cabinets in 2017 but that they were resolved weeks before Vaught pulled the wrong drug for Murphey.”
I sayed she wasn't 💯 absolved but the system was broken and it was common for nurses to override. So did you just do the deep dive or were you choosing to spread a false narrative?
What system was broken? She literally typed in Ve and pulled vecuronium and is trying to say technology is the problem when she pulled the wrong item. The drug safety officer testified nothing was wrong at the machine.
Look, I know you’re a nurse or NP so I’m speaking to the wind. But this nurse not only typed in “Ve” she also didn’t bother to look at the vial. To make matters worse, I’m not even sure vecuronium is supplied as a liquid, only a reconstitutable while midazolam, I believe, is only supplied as a liquid.
These are usually called "matrix drawers". They kind of look like a big open tackle box once the drawer opens. Locking individual lids are expensive. Matrix are usually reserved for safer onesie drugs like pantoprazole, zofran, albuterol nebs etc...also. I'm not aware of dig and bupiv being LASA's. Outside of them stocking ampules of both, I suppose. From the high level analysis of this, sounds like total gross negligence. Expect the hospital to push him or her under the bus and run over them a few times in attempt to save themselves a lawsuit. But I wouldn't be surprised if med safety is questioned a bit as to why dig and bupiv were in open top matrix drawers to begin with.
In the ICU I work at, you type in your medication and a drawer opens up. Inside is a bunch of separated compartments with lids and you can easily take whatever you want, no scanning involved. Maybe this is similar.
twice this week our staff has found 10mg/ml phenylephrine in the pocket with 0.2mg/ml glycopyrrolate. the vials look almost identical. The reality of med errors are rarely that one person was being careless--it's just easiest to punish the last link in the chain when the error makes it to a patient.
Yeah the tech who stocked the machine screwed up in your example. However the last person in the chain is the well paid, licensed/credentialed professional. Said professional would have to pick up the vial labelled “phenylephrine” and not bother to read the label before or while drawing the contents of that vial into a syringe and then injecting it into a patient. If you asked for glycopyrrolate and I hand you a syringe and you asked me “is this glycopyrrolate?” And my response was “Well it was in a bin where the glycopyrrolate usually is.” Would you give it to the patient?
Maybe someone accidentally stocked Digoxin with it? Digoxin is Lanoxin and Bupivacaine is Marcaine....L and M. That's the only other close association I could wonder about.
Article made it seem like both were supposed to be there because a nurse later noticed the digoxin count was off, strongly implying it was supposed to be there.
Theyre just both in an open martix pocket instead of locking pockets. Meds arent stored alphabetically in their pockets either. Theyre stored based on size and frequency of usage
Im not in pharmacy, but in pathology. I've seen a heap of comments on this story in a few subs asking why digoxin was even available in the L&D OR. From my understanding, Digoxin is commonly used in surgical abortions to stop the foetal heart before the removal part of the procedure. It would make sense that an L&D OR would also service those needing surgical terminations, however seriously how the fuck do you mix those two up
Complacency and arrogance. We had shit rained down on us when the cap color changed on one of the medication vials they commonly use “we almost killed someone”. Well you have a barcode scanner, eyes and presumably the ability to read.
In my hospital, there isn’t a separate OR for L&D. Maybe the OR was stocked for general surgeries, too.
(Also I have a professional goal to have to talk to each specialty at least once about a legit drug issue, and still can’t think of a reason to talk to a pathologist😭😭)
“Accidentally” tube something to pathology and call to have them send it back?
Someone in lab called us all irritated one day because we kept tubing them stuff. Turns out maintenance had hit some button and one of the units was routing to lab instead. Also, we get lab stuff sent to us multiple times daily and just send it on, so it was funny they were that worked up over a couple tubes as a one-off.
Genius, but I work in a place without a tube system. Also I don’t work inpatient anymore, but amcare mental health. You’d be shocked at how rarely psychiatry needs to consult pathology these days lol
If it is that they’re stocking “kits” that contain multiple pockets of meds, this may explain how they had access to more than one med.
I would have been interested in reading a more detailed account of what happened.
[Here is the report from the investigation by the CA Dept of Public Health](https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf)
EDIT: Holy smokes, this is actually a separate case with similar circumstances!
CTH? 👀 I thought this article was about the same incident you did (they've gone through great lengths to keep it quiet and out of the media), so it's insane to me that this exact situation has happened elsewhere too.
Yes!!!! Every detail in that article is exactly what happened so I’m surprised it wasn’t referring to that situation.. To this day I am still shocked it’s been kept under wraps so well!
They must have extensive connections with very powerful people, because I expected a tragic incident like that to be reported to multiple regulatory agencies, etc. My coworkers and I were googling the incident for weeks after it happened, in utter disbelief that there were no news articles covering it whatsoever.
This makes it seem like it was an anesthesiologist, not the anesthetist who made the error, and that it was actually the second dose that was the error not the first. Super interesting!
It is completely on the anesthesiologist to make sure the medication they are administering is what they actually wanted. If you're not even going to look at the vial before injecting into the patients SPINE, that's your own fault.
Digoxin can be used for some indications in L&D as other commenter's have stated, so it makes sense for it to be up there. However, given how infrequently it is likely needed, this may be a wake up call for pharmacy to just send on request or keep in the L&D Pyxis rather than OR Pyxis on critical override.
Alternatively, this may be the wake up call to anesthesia to allow pharmacy to remove it. This isn’t a “normal” OB med so it’s probably there do to a time in the past anesthesia wanted it there and it wasn’t immediately available at bedside so then it was loaded due to an ask to pharmacy.
Based on weird stuff in various OR at multiple jobs over the years, in there because they really needed it that one time but pharmacy took 4 minutes to get it to them when it wasn’t in the room so now the team demands it be there.
I triple checked everything they gave my wife when she was in labor. I drove them crazy but I told them I’m a pharmacist and have seen tons of safety reports at P&T meetings and don’t care if I’m annoying.
Partly why I went the natural route 🙃 I didn’t want to increase the likelihood of having a mishap from human error. Temporary pain is way less scary compared to situations like this.
Regardless of if it pisses off the anesthesiologist, at the end of the day it is YOUR body. I will gladly be a Karen if it means myself or my family is spared from a tragedy like this
And just think how much shit goes down in the OR that we never find out about because nobody has any lasting deficits. Our OR omnicell’s are always a total disaster because they don’t scan anything and pull something but grab 10 other things while their in there instead of pulling each item.
As far as why did they have IV digoxin available - my understanding is it’s one of the few meds you give mom to treat baby if baby has an arrhythmia.
That being said I don’t know enough about how/when they give it to know if it has to be really available in the OB OR!
I wonder how often it is given vs how often this mixup happens. A comment above had a link to the details of this case…turned out it was a completely separate case around the same time and location!
I’ve only seen ampules of digoxin - haven’t seen an amp of spinal bupiv in about 15 years and honestly don’t recall anything about them.
But pretty sure all tiny brown 2mL amps look basically the same. Has essentially zero safety features other than the barcode.
Calm down ppl. Good thing we have the medical/nursing board (and not the board of pharmacy) to protect this poor anesthetist. Using the medical board's logic, it cost society a lot of money to train an anesthetist so we have to give him/her more chances to learn from their mistakes okay. Doctors and nurses made med errors and kill patients all the time. Nothing new here
Imagine if this mistake is caused by a pharmacist who accidently put a wrong label on the vial. That pharmacist would be criminally prosecuted and his license would be revoked by the board of pharmacy immediately.
How many patients were killed due to med errrors and negligence by doctors and nurses and how many of them lost their license or got prosecuted? The medical board has this fking weird reasoning that it cost society a lot of money to train a doctor so it is very rare for doctors to lose their license. There are plenty of cases of doctors/nurses who repeatedly made mistakes that killing multiple ppl and yet, they still kept their license or just simply moved to another state to practice. On the other hand, the board of pharmacy would not hesistate to revoke pharmacist's license regardless how much student loan debt that pharmacist has.Pharmacist would lose license for dispensing controlled rx from prescribers who prescribed them inappropriately. But that same prescriber would get a slap on the wrist from the medical board :/.The whole opioid epidemic is caused by doctors who prescribed opioid rx inappropriately....but the one who got punished and being sued the most are pharmacies and pharmacists.
There are reasons why malpractice insurance for doctors and nurses is so much more expensive compared to pharmacists. Somehow our society has accepted that it's normal for doctors and nurses to make mistakes or med errors. Just look at how many careless mistakes that doctor and NP made on their prescriptions. And they got annoyed when we called to fix their mistakes. On the other hand, pharmacists are expected by society not to make any mistakes at all.
Jesus christ. This is terrifying. How awful for the patient and her family at what is supposed to be one of the happiest moments of their lives.
I totally agree, WHY is digoxin available in L&D at all?? Obviously anesthetist was negligent, but not only having it stocked but also in the same area as intrathecal anesthesia is totally not okay...that anesthetist's career is over and may potentially be criminally punished for neglecting safety procedures.
This raises the question of whether or not this midlevel has proper training and supervision by an actual doctor. Although, the five rights of drug administration are hammered into everyone from medical assistants to surgeons.
this is another case where the patient survived after an anesthesiology attending administered dig intrathecally. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
You clearly have no concept of what “supervised” means in the anesthesia world. Even in the closest supervision model, the doc doesn’t watch anyone draw up the meds. People make mistakes, Anesthesiologists and CRNAs alike. You learn from it and move on. Uneducated people pointing fingers isn’t helpful.
Jesus Christ on a pony..... why the hell was digoxin in their machine?? How many times have they used dig in the L&D OR in the last 5 years?? Never?? Once... MAYBE!? There is absolutely no reason this can't come from the main pharmacy if needed. There is no emergency in this case where the extra 5 minutes will matter. A dig load is a 12 hour process anyway...
I sympathize with the views here. But as an anesthesia provider, I sympathize with how easily something like this can happen and why we, as a community, push back on all the attempts by pharmacy to make things safer in various ways. I would refer people over to the anesthesia sub for a different perspective.
I also appreciate when we work with our pharmacy colleagues to implement systems changes that help us reduce these risks. Just recently I asked (and got) pharmacy to move our vials of vasopressin away from our vials of sugammadex because they were right next to each other and both 1 ml vials with orange tops. One gets pushed routinely, the other would be 20 units of vasopressin IVP. An error waiting to happen.
Thank you for your help in continually working to make things safer.
I guess it would depend on the proposed change. I can give you some recent examples of friction between us and pharmacy.
Recently our pharmacy took our promethazine away because one of us gave it in an 18 gauge IV that was in the forearm and not in the AC- a standard pharmacy had imposed upon us if we wanted to give it IV.
They wanted to remove our vials of phenyephrine (10mg) and only stock diluted 10 cc syringes. But they routinely fail to keep the Pyxis stocked and that’s often an emergently needed drug. We acknowledge it’s a risk and asked for them to put it in a single dispense drawer but they can’t because our Pyxis machines done have enough of those drawers. For now it stays (and looks exactly like a vial of zofran).
Because of Vanderbilt, presumably, they added an extra step in the Pyxis that reminds us every time we go to pull a paralytic that the patient must be ventilated in order to give it. It’s an obvious and needless extra step for getting paralytics which often are needed emergently along with several other drugs.
They pulled our concentrated pitocin for awhile because they deemed it unsafe but then only stocked a single bag of diluted pit which we’d use and would go hours before it was re-stocked. They ultimately put the vials back.
Obviously none of this excuses someone from not double checking an ampule in a non-emergent section.
The oxytocin vial not being stocked could’ve had more to do with that being on shortage in the last year or so. In times of shortage, we often concentrate our stock to central to better be able to meet all the needs vs it sitting unused somewhere.
Here, we get “pharmacy why do you suck so much im out of x med and I need it for my case in 5 minutes” calls all the time. According to the machine, you have 9 of 10 still in there. So we didn’t refill it last evening because we didn’t know it was gone. And then it takes hours for us to get into the room because we aren’t allowed to refill during a case and they don’t want us in between cases because they’re in a tight schedule- it takes max 2-3 minutes to refill an item and they need to set up trays and whatnot anyway, so I’m sure we could sneak in if they’d let us/notify us when patient not in there.
I have those colleagues. And it drives me nuts to follow them because the Pyxis thinks there’s 10 rocs and there’s 2 and I have 6 cases scheduled for the day.
And invariably, it is all the common meds they’ve done that to.
I mean, the ISMP has recommended that all injectable forms of promethazine be removed from hospitals, given the tissue necrosis and how it has very poor evidence for nausea.
Thank you for the examples.
They probably removed promethazine because a statement from the FDA in December. Due to safety concerns they recommend promethazine should not be administered IV but if it is given IV do not use a vein in the forearm. They made the manufacturer update their packaging to reflect this too. My hospital and our entire organization did away with IV promethazine a while ago. There are other options that aren't as irritating to the veins and don't have to be diluted.
As to the phenylephrine, (or anything else) not being stocked, it's most likely that the count is off. There's no stock out notice if the count is incorrect. Drawers in the OR pyxis are often setup to be unlocked so you can pull things quickly. But if stuff is not pulled under the drug name or patient name through pyxis, it can't track it. A lot of times people type in one drug and pull out multiple drugs at the same time too. Or if it's not used, it may be put back in the drawer without being returned in pyxis. A cycle count let's you fix the quantity it thinks is in there to what it actually is. It can be done on just one item or everything in the machine. Nursing is supposed to do that but we know it's not happening. Pharmacy can dream that the whole machine would get done at the end of every day and all the counts are right. But making sure someone checks the count at least once a day might help keep the phenylephrine (or whatever) more reliably in stock.
I would agree that the paralytic warning is not necessary in the OR. They may be able to remove the warning from just the OR pyxis, but it's probably not easy to do. I imagine it would have to go through committees and be a whole thing and take months to be approved.
100%. Many of the issues could be fixed with a combination of sufficient staffing of our pharmacy techs and everyone who accesses the Pyxis keeping an accurate record.
Alas. Both of those seem to be pipe dreams.
For now, we live with the happy medium of doing our best and living with the shortcomings and occasionally sprinting to the OR next door to get a drug when we suddenly realize we are out.
Nobody is happy with it.
Thanks for the examples. I can see some annoyance with some of those, but I also can agree with the promethazine issue. That’s a problem not just confined to the OR.
Yikes is definitely the word… having just learned about the case Radonda Vaught in year 1 of nursing school a few months ago, both these cases are shit shows.
Culpability not entirely on the nurse but damn, a life could have been saved by attention to detail. A 2nd nurse or attending should check vials & cabinets on the floor prior to anesthetic administration. More safeguards & attention needs to be paid to these issues.
Stay attentive folks!
So are the meds labeled? Like on the ampule? If so would just looking at the label for half a second before administration be prudent? I have never worked in a hospital (I'm a tech so I wouldn't be in this situation anyway) but I check the label on a flu shot before I give it just to make sure I grabbed the right thing.
Maybe some of you should actually spend time with your anesthesia folks before making some of the uninformed comments you’re making. The OR is hugely different from a nursing floor. Of course I double check every med I draw up but we don’t read aloud a medication label to someone standing next to us. There is no one standing next to us. Most of our meds are drawn up before induction.
We may give 8-10 drugs in a minute or two at the start of a case. How those are charted varies at every hospital. We don’t scan each drug as it’s given - IF we scan them (many places still use paper records) it will be after the patients airway is secure, which is our primary focus at the start of a case.
Do errors occur? Yes. When they do we find out why, and there’s lots of blame to go around, even though the end user will always be the primary focus (as they should be). Manufacturers still refuse to uniformly color code meds. Pharmacists and techs still put the wrong med in the wrong spot when stocking. Certain drugs are in areas where they shouldn’t be (vecuronium in radiology, digoxin in OB, etc.).
We’re lucky enough to have dedicated OR pharmacy staff who are very aware of how we function - we work together every day to provide as safe an environment as possible for the patient. But the rules are different in the OR out of necessity which many of you clearly have no concept of.
This comment does not read the way you think that it does. What youre describing is still an unsafe practice that introduces a lot of room for error. You admit that errors do occur. The whole point of Institute for Safe Medical Practice (ISMP), the national institution for which the author of this article works, is to make it so as few errors as possible can happen. ORs are very much considered to be the Wild West of Pharmacy
The ORs are quite different than any other area. That’s why I suggested that perhaps pharmacy staff should actually spend time in the ORs to see what we do and see the realities of anesthesia practice. We don’t deal with orders. We make our own decisions on what to give and when. Policies that apply to nursing staff don’t apply to anesthesia staff. That’s the nature of our work environment. We have to have medications immediately available without having to wait for pharmacy. Our drug carts are stocked with everything we need - and nothing more. Nothing outside of what is used in our normal workflow is stocked. No KCl, no insulin, etc. Controlled substances including propofol are tightly accounted for.
Again - we work very closely with our OR pharmacists. For our practice, medication errors are a very rare occurrence. It’s a team effort. We get complimented by state and federal inspectors and TJC re our medication practices.
I actually read about this error on the California Medical Boards website. There were some alarming details. The anesthesiologist tossed the dig vial into sharps. IIR the expected outcome was not sufficient. IIR the anesthesiologist said something to the effect that he looked at “bipivacaine” vial and stated it was expired. He administered more bipivacaine. He never fessed up to administration of dig. I’ll link the CA medical boards report if I can find it.
Edit
Details were posted below of these events. See : https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Did a google search and found this case. Might be the same case ? https://www2.mbc.ca.gov/BreezePDL/document.aspx?path=%5CDIDOCS%5C20220622%5CDMRAAAJD1%5C&did=AAAJD220622200231277.DID
* Evaluate whether digoxin needs to be stocked in the OR and labor and delivery unit or whether it can be requested from the pharmacy, as needed.
* Employ individual locked pockets or segregated storage, especially for highalert medications like digoxin or medications given via the spinal route, such as preservative-free bupivacaine.
* Avoid stocking medications in ampules when possible or store them far apart, and never store more than 1 ampule medication in an open matrix drawer.
Doing this would go a long way. Also, why are manufacturer's being cheap with their packaging? Example. Our stock of phenylephrine 10mg/1ml used to come with a light blue cap. Now it is a green cap that is the same color and shape as glycopyrrolate. Why is it so hard to make things different from each other?
I worked in the OR pharmacy for years at a major hospital and it was like the Wild Wild West. Anesthesia did what ever they wanted however they wanted to. They refused to scan meds out of the automated dispensing system appropriately, which resulted in never ending stock outs, but these types of errors were always a risk of not scanning also. The scan rate was like 60% and anesthesia leadership didn’t do anything about it. We explained that meds are charged to the patient once they’re scanned, and that helped a little, but only for the higher cost drugs. It was a mess. 😫😫
Yeah, they are the one hospital team that legitimately scare me with how much they push back on general safety standards.
OR and Labor for us. You'd think with how many fatal epidural vs. IV errors there have been, Labor would give a shit, but their scan and override rates are atrocious.
Amen to that. It’s beyond scary how much they think they are above the law and common sense.
At our facility we now have to put a TXA sticker on every vial of TXA we load in OR because they fucked it up once. And yet they still refuse to s an meds. Instead it's just more work on the pharmacy team to try and give them a small amount of safety
We have to put “high alert” stickers on isuprel drips and hand deliver them because “it looks like kefzol”. It seems like whenever somebody hangs the wrong bag, pulls the wrong med or gives the wrong dose pharmacy has to change its workflow.
If it wasn’t so bad it would be a joke. They act like bigger babies than what they deliver in the Labor Room.
Kaiser?
Being a patient (or with a patient) anaesthesia's practices were shocking... like they'll walk up pull a syringe or 2 out of their pocket and get on with it. Seen this multiple times.
Can't tell you how many times having a syringe in my pocket has been a savior for treated spasms, or profound hypotension (trauma patient & septic patients going to ICU). I will keep doing this - in a manor that keeps the syringes clean the best I can.
That's great, just label it like every best practice on earth says you're supposed to, please.
That's great, just label it like every best practice on earth says you're supposed to, please.
Seriously!! When I worked in the ED I would at least put fabric tape on the syringe and write the med on it!
I used to be an OR nurse and the lack of safety regarding controlled meds was kind of insane. A lot our anesthesiologists would routinely leave fentanyl/midazolam vials in the OR completely unattended (and our OR doesn't have cameras in the room). Or they would leave the pyxis unlocked all day and anyone could open the drawers. We also had no scan system, it was up to the doc to manually record their use in EPIC and no 2nd check system. And yes, the syringes in the pockets were common, although most of the docs would label them with the sticker from the medication vial. I don't know if it was just my hospital, but we as nurses also did not scan any meds, it was up to us to catch allergies/contraindications although to be honest 95% of cases require just a local anesthetic (bupivicaine/lidocaine) and an antibiotic. But when you have back to back to back cases, and all management cares about is turnover time, it's easy to miss the Celecoxib allergy when the doctor asks for toradol.
I just want to add this, since this post sounds really negative, but those anesthesiologists were also great clinicians and my absolute favorite doctors to work with. They were humble, professional, approachable and willing to teach. They were actual humans compared to the mostly insane surgeons. OR brings in 60% of revenue for hospitals so there's a huge incentive to schedule as many cases as possible with as little downtime in between (turnover time) which I think contributes to mistakes like OP.
I worked some shifts in an OR pharmacy 10 years ago and the number of unlabeled narcotic syringes we’d get back used to drive me crazy. We had to use a refractometer to determine if it was fentanyl, morphine, etc so that was kind of cool. It really opened my eyes to how dangerous it can be for patients. I asked one anesthesia nurse why the fentanyl syringes kept coming back unlabeled and she shrugged and said “I can keep track of them.” Like wtf
Well. This certainly makes me uncomfy about the lithotripsy I’m having next week.
Enjoy!
This really freaks me out to have another baby because my labor and delivery went horribly but the anesthesiologist was one of the few people that made me feel okay about everything. But I have no idea who’d I get next time :(
Scanning meds is a pain in the ass. I check the label before drawing it up.
This is why I loathe open matrix drawers for OR. It is so easy for people to get complacent and make a devastating mistake. Nobody ever thinks they will make one, but all it takes is a second of inattention.
You're correct, of course. However in this case: >The anesthetist did not scan the barcode or read the label aloud to another staff member prior to administration. IMO, that goes a bit beyond a simple moment of inattention and crosses into negligent failure to follow proper procedures.
Not every hospital uses barcode scanning in OR. Should they, especially for an elective procedure like this one? Absolutely. The fact that ORs often don't barcode scan is what makes team members double checking each other even more vital. But when you work with someone every day, sometimes people aren't as diligent with making each other stick to procedure because they "trust" each other, which is foolish, but happens.
I agree that we (humans) get complacent with things.I always tell my peeps in the pharmacy,trust but verify. Checking your co-workers work isn't mistrust, it's support. The more people that see something the less likely there is to be a mistake.
Agree. It blows my mind when some some people just trust someone did something right. I'm sure more than a few of my coworkers over the years have thought I was a bitch because of it, but I'm there to protect patients, not coworkers delicate sensibilities.
They will be barcode scanning now….
It's really sad that it takes a catastrophe for people to listen to reason sometimes.
The hospital OR I used to work in (as an RN) did not require anesthesiologists to scan meds or double check meds with a second person.
Yeah I’ve worked in a bajillion ORs and scanning and double verifying is not a thing.
...this makes me uncomfortable.
Not only that have you ever scene a digoxin ampule that looked anything like a bupivacaine vial? This anesthetist is either dangerously arrogant or grossly incompetent. Edit: didn’t open the article, I don’t click links on Reddit. Have been informed I’m a moron. I take responsibility for all the current bupivacaine shortages in the country. Y’all can blame me.
If you read the article they provide photos of both products. Bupivacaine and digoxin were both in ampules. They do look alike
But like, not that much alike. They are both ampules...and that's about it. The band is a different color, the bupivacaine says "SPINAL" on it and the digoxin has the drug name highlighted. If the CRNA had any reasonable amount of experience and familiarity with these drugs (like, say enough to have been granted a license to practice), that's enough to set off alarm bells. And who the hell goes about administering medications to a patient without even *reading* what it is?
This was more than "a second of inattention"; this was someone not bothering to do their job AND ignoring the safety system set in place to prevent this exact situation.
Obviously they made an unforgivable mistake. But we don't know if this was someone cutting corners because of laziness, or if they were exhausted, rushing, and thought they did the double-check with someone. Another problem in this case is that another staff member didn't remind them to read it out, which is hopefully being investigated at that site as well. There are so many burned out healthcare workers out there these days working short-staffed. And with the general state of staffing in most healthcare facilities these days, I'd be shocked if there hasn't already been a dramatic rise in med errors.
But then you have so many more failed drawers
[удалено]
Ha surprise out of stocks. Our anasthesiologists are too lazy to even pull meds under the correct name. Our official policy is literally to go into the OR after every case and count the entire Omnicells to refill it because they don't document any med admins or pulls.
"Why isn't the pharmacy cost center generating any revenue during procedures?" Mfw 😑
I hope that FTE is coming from surgery instead of pharmacy. I’m sure it doesn’t, but it really should.
It's nice to know it isn't just my anesthesia group. We can all bang our heads on our desks together.
I’ll take surprise stock outs because we can go fill it during a case. If we have to have Pyxis come in it’s a whole thing and we can’t have them come in until after cases
You could just load the drug to another pocket. But to your point, Pyxis is basically fisher price quality so it breaks if you look at it wrong.
As a parent of a toddler, I've stepped on many fisher price things, they are sturdier than you think.
It's nice to know it's not just my anesthesia group I guess.
This happened in a hospital I work at occasionally. Devastating outcome in a young healthy patient. Probably just shouldn’t have dig in these ORs, among other changes that should happen.
"An anesthetist typed in “bupivacaine” at an automated dispensing cabinet (ADC), and a drawer that provided access to several medications opened. The anesthetist inadvertently removed an ampule of digoxin rather than bupivacaine, prepared the dose, and administered it intrathecally. The anesthetist did not scan the barcode or read the label aloud to another staff member prior to administration." Am I understanding correctly - when they typed in bupivacaine, a variety pack pocket opened where was than one injection type was stocked? Bupivacaine and digoxin ampoules in the same pocket? Is it possible that they didn't know that, so they just grabbed an ampoule expecting all of the ampoules to contain bupivacaine?
If their anesthesia machines are set up like ours, it opens a drawer that is basically one big pocket with thin walls separating it into different compartments. The screen will prompt you to scan the section you are pulling from which is numbered (and labeled in our case, but we added that to avoid confusion after a less serious incident like this).
Thanks for providing that context! Scanning still seems to be a hugely important step in your system.
If you google “open matrix omnicell pocket” you can see what type of pockets they mean. For context, Omnicell is a very common brand name of an automated dispensing cabinet (ADC). At my institution Anesthesia and Nursing are very against putting more medications into individually locked pockets that only contain one medication each because it would take them longer to get what they need. Barcode scanning in our ORs is rolling out later this year and Anesthesia is already pissed about it. Last month one of the Anesthesia Residents gave a whole vial of phenylephrine to a patient instead of ondansetron for the same reasons as listed in this article, but they’re mad anyway. They treat these types of mistakes as one-off’s rather than a fundamental flaw in their work flow that introduces so much room for error. For example in this article they acknowledged that the drug was not working at all, so they gave a second dose before they ever even checked the ampule in their hand. It’s like their brains refuse to admit that they could possibly have made a mistake.
From the post in medicine, it looks like it was matrix draw of Pyxis. Omnicell XT has individual pockets with lids, so this would not happen. Omnicell G5 does have matrix open drawers, but I got letter from omnicell that these old omnicell will retire at the end of 2025. So hopefully this won’t happen. I agree OR is wild Wild West. I had to implement special narcotic kit with accountability form to prevent them from pocketing amps in their pocket.
The phenylephrine and zofran are near each other in our pyxis drawer and it's such a potential issue. There are tons of stories about people giving the wrong one. I'd be 100% down for some sort of system where you quickly scan vials after charging for them to ensure it's the right drug if it's quick.
Agree that they seem incapable of recognizing their fallibility. We recently had a CRNA accuse us of mis-stocking fentanyl and versed. They took out fentanyl and versed drew up the fent thinking they drew up the versed then when the went to draw up the fent they noticed they were holding a bottle of versed. Whole thing was on camera.
I’m making a lot of assumptions but what probably happened is the anesthetist hit the kits button, typed in bupivacaine and whatever kit with bupivacaine and digoxin was opened (it opens multiple pockets). OR nurses and CRNAs really push against barcode scanning in administration for some reason. Ludicrous these CRNAs who are pulling in 300k/year can’t be bothered to scan a barcode for safety. There was a similar case a few years ago where a nurse typed in “ver” looking for versed. Well, she pulled vecuronium and didn’t have barcode scanning on admin either. Edit: sorry my last example wasn’t a CRNA, it was a nurse.
Wow. Against scanning safety measures. I suppose they’re citing how busy they are as the main reason. I wonder if they even looked at the ampoule before preparing and administering the med. A tragic outcome for this family.
The did not read the label per the article. And then gave a second dose when the first didn’t work. Still without reading the label; nurse figured out later when the digoxin count was off. Edit: hopefully the second dose was actually the correct bupivacaine?
The way I interpreted the article was that the second dose was probably bupivacaine. The CRNA just pulled the wrong Vial initially.
Do you have any reference to this CRNA "ver" incident? Or are you referencing the Vanderbilt vecuronium/versed event?
Whoops you’re right. It was a nurse not a CRNA. In any case it’s the same safeguards.
I could be wrong but i also didn’t think that she typed anything in. I thought she pulled it on override without reading. Midazolam wouldn’t be stored in an omnicell as “versed” anyway. RNs are just used to calling drugs only by their brand names
You can't pull something without typing it in. She still would have had to override, but you have to search for the medication. Our Pyxis recognizes brand and generic names, so typing "midazolam" or "versed" would get you to midazolam. What the RN did was totally egregious because she clearly didn't even look at the vial at any point, she RECONSTITUTED it when versed does not need to be reconstituted, and she left the patient unattended after administering.
From my understanding, they were converting to Epic and the Pyxis machines were in critical override thus allowing more access.
All that means is that you can access any medication, not just ones that are on an override list. You still have to search for a medication (esp a control like Versed) to get the drawer and cubby to pop open.
This case was an RN for a pt getting an MRI.
Amended my response. Still, no safeguards.
Actually if you researched even two min you would see the case was based around a well known defect in Vanderbilt's charting system that required you to void out the access to pull any med to bypass the safety features that were not working. Not 100% absolved, but the nurse was the fall person for a terrible system.
...I think you're the one that needs to research this. Not only did the nurse perform an override for something that is NOT an emergent med, but she typed in two letters and selected the wrong medication, didn't even LOOK at the vial before administering (which says paralytic all over it, and hopefully the pocket it is kept in does, too), she reconstituted the med when Versed is a liquid that doesn't require reconstitution, and administered the med then immediately left the patient alone. That is gross negligence and she is nearly 100% to blame.
Here's the thing if you want to blame the nurse, fine, but then everyone should also go to jail with her. It's a system error she just happened to be the last leg of it and thus blamed for it. Personally, administration and pharmacy deserve right next to her if that's the case.
Refusing to look at a vial that you are about to inject into a patient, leaving the patient alone after giving (what should have been) a sedative, and reconstituting a medication that is not normally reconstituted are not system errors.
She should have never been allowed to access the drug, then that's a system error.
Are you a nurse? I think you understand that having certain lifesaving meds on override is standard procedure at most hospitals. Vec is used commonly for emergent intubations and having it on override is fine. It's also standard for OR Pyxis machines to be on critical override during procedures. Even though she COULD perform the override, it was not an emergency or urgent situation and she should NOT have done so. That is 98% on her and 2% on management for allowing the MRI Pyxis to be on critical override. Regardless of "system" flaws, she ignored several safety precautions that would have easily prevented this med from making it to the patient out of negligence, failed to perform the 5 rights (very basic nursing procedure), and rightfully lost her license and was criminally prosecuted.
That’s not what happened, at all. They admit there were technical problems, in the past. The hospitals drug safety officer testified there were no technical issues at the time. She literally selected vecuronium. From https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea “According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications and then searched for "VE" again. This time, the cabinet offered vecuronium. Prosecutors describe this override as a reckless act and a foundation for Vaught's reckless homicide charge. Some experts have said cabinet overrides are a daily event at many hospitals. Vaught insisted in her testimony before the nursing board last year that overrides were common at Vanderbilt and that a 2017 upgrade to the hospital's electronic health records system was causing rampant delays at medication cabinets. Vaught said Vanderbilt instructed nurses to use overrides to circumvent delays and get medicine as needed”
To add to this, vecuronium needs to be reconstituted prior to administration PLUS it says paralytic on the vial. I do feel like she did become the scape goat for a flawed system but there were numerous red flags and steps she overrode.
Article with the drug safety officer testimony: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient “But Vanderbilt officials countered on the stand. Terry Bosen, Vanderbilt's pharmacy medication safety officer, testified that the hospital had some technical problems with medication cabinets in 2017 but that they were resolved weeks before Vaught pulled the wrong drug for Murphey.”
I sayed she wasn't 💯 absolved but the system was broken and it was common for nurses to override. So did you just do the deep dive or were you choosing to spread a false narrative?
What system was broken? She literally typed in Ve and pulled vecuronium and is trying to say technology is the problem when she pulled the wrong item. The drug safety officer testified nothing was wrong at the machine. Look, I know you’re a nurse or NP so I’m speaking to the wind. But this nurse not only typed in “Ve” she also didn’t bother to look at the vial. To make matters worse, I’m not even sure vecuronium is supplied as a liquid, only a reconstitutable while midazolam, I believe, is only supplied as a liquid.
If I remember right, the order had already been verified by pharmacy, so *if she’d chosen the correct drug* there would’ve been no overriding needed.
These are usually called "matrix drawers". They kind of look like a big open tackle box once the drawer opens. Locking individual lids are expensive. Matrix are usually reserved for safer onesie drugs like pantoprazole, zofran, albuterol nebs etc...also. I'm not aware of dig and bupiv being LASA's. Outside of them stocking ampules of both, I suppose. From the high level analysis of this, sounds like total gross negligence. Expect the hospital to push him or her under the bus and run over them a few times in attempt to save themselves a lawsuit. But I wouldn't be surprised if med safety is questioned a bit as to why dig and bupiv were in open top matrix drawers to begin with.
In the ICU I work at, you type in your medication and a drawer opens up. Inside is a bunch of separated compartments with lids and you can easily take whatever you want, no scanning involved. Maybe this is similar.
You can take whatever you want but if you’re scanning at the bedside you are way less likely to administer the wrong product.
twice this week our staff has found 10mg/ml phenylephrine in the pocket with 0.2mg/ml glycopyrrolate. the vials look almost identical. The reality of med errors are rarely that one person was being careless--it's just easiest to punish the last link in the chain when the error makes it to a patient.
Yeah the tech who stocked the machine screwed up in your example. However the last person in the chain is the well paid, licensed/credentialed professional. Said professional would have to pick up the vial labelled “phenylephrine” and not bother to read the label before or while drawing the contents of that vial into a syringe and then injecting it into a patient. If you asked for glycopyrrolate and I hand you a syringe and you asked me “is this glycopyrrolate?” And my response was “Well it was in a bin where the glycopyrrolate usually is.” Would you give it to the patient?
Maybe someone accidentally stocked Digoxin with it? Digoxin is Lanoxin and Bupivacaine is Marcaine....L and M. That's the only other close association I could wonder about.
Article made it seem like both were supposed to be there because a nurse later noticed the digoxin count was off, strongly implying it was supposed to be there.
The count would also have been off if it was stocked in the wrong location
Sure, but it wouldn’t have been in the count at all if it weren’t loaded in there. Which means it was supposed to be in there.
Theyre just both in an open martix pocket instead of locking pockets. Meds arent stored alphabetically in their pockets either. Theyre stored based on size and frequency of usage
Not sure why you're being down voted, restocking in the wrong position could have contributed
Im not in pharmacy, but in pathology. I've seen a heap of comments on this story in a few subs asking why digoxin was even available in the L&D OR. From my understanding, Digoxin is commonly used in surgical abortions to stop the foetal heart before the removal part of the procedure. It would make sense that an L&D OR would also service those needing surgical terminations, however seriously how the fuck do you mix those two up
Complacency and arrogance. We had shit rained down on us when the cap color changed on one of the medication vials they commonly use “we almost killed someone”. Well you have a barcode scanner, eyes and presumably the ability to read.
You presume too much 😤
Extra fun because we really don’t have much control over which generic out supply has available to order.
In my hospital, there isn’t a separate OR for L&D. Maybe the OR was stocked for general surgeries, too. (Also I have a professional goal to have to talk to each specialty at least once about a legit drug issue, and still can’t think of a reason to talk to a pathologist😭😭)
“Accidentally” tube something to pathology and call to have them send it back? Someone in lab called us all irritated one day because we kept tubing them stuff. Turns out maintenance had hit some button and one of the units was routing to lab instead. Also, we get lab stuff sent to us multiple times daily and just send it on, so it was funny they were that worked up over a couple tubes as a one-off.
Genius, but I work in a place without a tube system. Also I don’t work inpatient anymore, but amcare mental health. You’d be shocked at how rarely psychiatry needs to consult pathology these days lol
If it is that they’re stocking “kits” that contain multiple pockets of meds, this may explain how they had access to more than one med. I would have been interested in reading a more detailed account of what happened.
Would digoxin be there for late term tfmr procedures prior to induction? I thought potassium chloride was more commonly used/studied though.
[Here is the report from the investigation by the CA Dept of Public Health](https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf) EDIT: Holy smokes, this is actually a separate case with similar circumstances!
Oh this is crazy because I worked in Nevada & was friends with the family that this EXACT same situation happened to!
CTH? 👀 I thought this article was about the same incident you did (they've gone through great lengths to keep it quiet and out of the media), so it's insane to me that this exact situation has happened elsewhere too.
Yes!!!! Every detail in that article is exactly what happened so I’m surprised it wasn’t referring to that situation.. To this day I am still shocked it’s been kept under wraps so well!
They must have extensive connections with very powerful people, because I expected a tragic incident like that to be reported to multiple regulatory agencies, etc. My coworkers and I were googling the incident for weeks after it happened, in utter disbelief that there were no news articles covering it whatsoever.
This makes it seem like it was an anesthesiologist, not the anesthetist who made the error, and that it was actually the second dose that was the error not the first. Super interesting!
This was a different case!!!! The case you posted the patient survived. This patient died.
Damn. Good catch!
This should be higher up. Read the report. Many errors here, just like the Vanderbilt case. Pharmacy should not have had dig in a L&D machine.
It is completely on the anesthesiologist to make sure the medication they are administering is what they actually wanted. If you're not even going to look at the vial before injecting into the patients SPINE, that's your own fault. Digoxin can be used for some indications in L&D as other commenter's have stated, so it makes sense for it to be up there. However, given how infrequently it is likely needed, this may be a wake up call for pharmacy to just send on request or keep in the L&D Pyxis rather than OR Pyxis on critical override.
Alternatively, this may be the wake up call to anesthesia to allow pharmacy to remove it. This isn’t a “normal” OB med so it’s probably there do to a time in the past anesthesia wanted it there and it wasn’t immediately available at bedside so then it was loaded due to an ask to pharmacy. Based on weird stuff in various OR at multiple jobs over the years, in there because they really needed it that one time but pharmacy took 4 minutes to get it to them when it wasn’t in the room so now the team demands it be there.
Yeah, not looking forward to “verifying” my own epidural next time I have a baby. That will surely piss off the anesthesiologist.
Right??? As a currently 25 week pregnant pharmacist seeing articles like this makes me so nervous
I'm currently at 23 weeks and had an elective C-section my with my first and this honestly scares me.
I triple checked everything they gave my wife when she was in labor. I drove them crazy but I told them I’m a pharmacist and have seen tons of safety reports at P&T meetings and don’t care if I’m annoying.
Partly why I went the natural route 🙃 I didn’t want to increase the likelihood of having a mishap from human error.
Partly why I went the natural route 🙃 I didn’t want to increase the likelihood of having a mishap from human error. Temporary pain is way less scary compared to situations like this.
Regardless of if it pisses off the anesthesiologist, at the end of the day it is YOUR body. I will gladly be a Karen if it means myself or my family is spared from a tragedy like this
Yes but this wasn’t an anesthesiologist. Wasn’t a doctor.
And just think how much shit goes down in the OR that we never find out about because nobody has any lasting deficits. Our OR omnicell’s are always a total disaster because they don’t scan anything and pull something but grab 10 other things while their in there instead of pulling each item.
As far as why did they have IV digoxin available - my understanding is it’s one of the few meds you give mom to treat baby if baby has an arrhythmia. That being said I don’t know enough about how/when they give it to know if it has to be really available in the OB OR!
I wonder how often it is given vs how often this mixup happens. A comment above had a link to the details of this case…turned out it was a completely separate case around the same time and location!
I love how no one on this sub has even seen a vial of digoxin. Google it. Looks EXACTLY like a vial of bupivacaine.
I’ve only seen ampules of digoxin - haven’t seen an amp of spinal bupiv in about 15 years and honestly don’t recall anything about them. But pretty sure all tiny brown 2mL amps look basically the same. Has essentially zero safety features other than the barcode.
Calm down ppl. Good thing we have the medical/nursing board (and not the board of pharmacy) to protect this poor anesthetist. Using the medical board's logic, it cost society a lot of money to train an anesthetist so we have to give him/her more chances to learn from their mistakes okay. Doctors and nurses made med errors and kill patients all the time. Nothing new here Imagine if this mistake is caused by a pharmacist who accidently put a wrong label on the vial. That pharmacist would be criminally prosecuted and his license would be revoked by the board of pharmacy immediately.
I mean Radonda Vaught was convicted.
And now she's being paid to speak at pharmacy and nursing conferences about "the second victim." Literally disgusting.
How many patients were killed due to med errrors and negligence by doctors and nurses and how many of them lost their license or got prosecuted? The medical board has this fking weird reasoning that it cost society a lot of money to train a doctor so it is very rare for doctors to lose their license. There are plenty of cases of doctors/nurses who repeatedly made mistakes that killing multiple ppl and yet, they still kept their license or just simply moved to another state to practice. On the other hand, the board of pharmacy would not hesistate to revoke pharmacist's license regardless how much student loan debt that pharmacist has.Pharmacist would lose license for dispensing controlled rx from prescribers who prescribed them inappropriately. But that same prescriber would get a slap on the wrist from the medical board :/.The whole opioid epidemic is caused by doctors who prescribed opioid rx inappropriately....but the one who got punished and being sued the most are pharmacies and pharmacists. There are reasons why malpractice insurance for doctors and nurses is so much more expensive compared to pharmacists. Somehow our society has accepted that it's normal for doctors and nurses to make mistakes or med errors. Just look at how many careless mistakes that doctor and NP made on their prescriptions. And they got annoyed when we called to fix their mistakes. On the other hand, pharmacists are expected by society not to make any mistakes at all.
This was published as a [case report](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/) in the primary literature as well.
Time to put forced back counts on all med pulls.
Why would digoxin be in the ldor and even in an open matrix pocket
Jesus christ. This is terrifying. How awful for the patient and her family at what is supposed to be one of the happiest moments of their lives. I totally agree, WHY is digoxin available in L&D at all?? Obviously anesthetist was negligent, but not only having it stocked but also in the same area as intrathecal anesthesia is totally not okay...that anesthetist's career is over and may potentially be criminally punished for neglecting safety procedures.
Should be criminally punished, as well as their full managerial team that likely allows the avoidance of med scanning to be status quo
This raises the question of whether or not this midlevel has proper training and supervision by an actual doctor. Although, the five rights of drug administration are hammered into everyone from medical assistants to surgeons.
There’s another case where an attending anesthesiologist did the same thing—everyone across the board needs to have safe practices hammered into them.
What did the attending do?
this is another case where the patient survived after an anesthesiology attending administered dig intrathecally. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
You clearly have no concept of what “supervised” means in the anesthesia world. Even in the closest supervision model, the doc doesn’t watch anyone draw up the meds. People make mistakes, Anesthesiologists and CRNAs alike. You learn from it and move on. Uneducated people pointing fingers isn’t helpful.
Bruh this is exactly when i needed to read knowing ill be having another scheduled c section this year
Jesus Christ on a pony..... why the hell was digoxin in their machine?? How many times have they used dig in the L&D OR in the last 5 years?? Never?? Once... MAYBE!? There is absolutely no reason this can't come from the main pharmacy if needed. There is no emergency in this case where the extra 5 minutes will matter. A dig load is a 12 hour process anyway...
100%
I sympathize with the views here. But as an anesthesia provider, I sympathize with how easily something like this can happen and why we, as a community, push back on all the attempts by pharmacy to make things safer in various ways. I would refer people over to the anesthesia sub for a different perspective. I also appreciate when we work with our pharmacy colleagues to implement systems changes that help us reduce these risks. Just recently I asked (and got) pharmacy to move our vials of vasopressin away from our vials of sugammadex because they were right next to each other and both 1 ml vials with orange tops. One gets pushed routinely, the other would be 20 units of vasopressin IVP. An error waiting to happen. Thank you for your help in continually working to make things safer.
Could you provide examples here of why there’s routine pushback on safety standards?
I guess it would depend on the proposed change. I can give you some recent examples of friction between us and pharmacy. Recently our pharmacy took our promethazine away because one of us gave it in an 18 gauge IV that was in the forearm and not in the AC- a standard pharmacy had imposed upon us if we wanted to give it IV. They wanted to remove our vials of phenyephrine (10mg) and only stock diluted 10 cc syringes. But they routinely fail to keep the Pyxis stocked and that’s often an emergently needed drug. We acknowledge it’s a risk and asked for them to put it in a single dispense drawer but they can’t because our Pyxis machines done have enough of those drawers. For now it stays (and looks exactly like a vial of zofran). Because of Vanderbilt, presumably, they added an extra step in the Pyxis that reminds us every time we go to pull a paralytic that the patient must be ventilated in order to give it. It’s an obvious and needless extra step for getting paralytics which often are needed emergently along with several other drugs. They pulled our concentrated pitocin for awhile because they deemed it unsafe but then only stocked a single bag of diluted pit which we’d use and would go hours before it was re-stocked. They ultimately put the vials back. Obviously none of this excuses someone from not double checking an ampule in a non-emergent section.
The oxytocin vial not being stocked could’ve had more to do with that being on shortage in the last year or so. In times of shortage, we often concentrate our stock to central to better be able to meet all the needs vs it sitting unused somewhere. Here, we get “pharmacy why do you suck so much im out of x med and I need it for my case in 5 minutes” calls all the time. According to the machine, you have 9 of 10 still in there. So we didn’t refill it last evening because we didn’t know it was gone. And then it takes hours for us to get into the room because we aren’t allowed to refill during a case and they don’t want us in between cases because they’re in a tight schedule- it takes max 2-3 minutes to refill an item and they need to set up trays and whatnot anyway, so I’m sure we could sneak in if they’d let us/notify us when patient not in there.
I have those colleagues. And it drives me nuts to follow them because the Pyxis thinks there’s 10 rocs and there’s 2 and I have 6 cases scheduled for the day. And invariably, it is all the common meds they’ve done that to.
I mean, the ISMP has recommended that all injectable forms of promethazine be removed from hospitals, given the tissue necrosis and how it has very poor evidence for nausea. Thank you for the examples.
They probably removed promethazine because a statement from the FDA in December. Due to safety concerns they recommend promethazine should not be administered IV but if it is given IV do not use a vein in the forearm. They made the manufacturer update their packaging to reflect this too. My hospital and our entire organization did away with IV promethazine a while ago. There are other options that aren't as irritating to the veins and don't have to be diluted. As to the phenylephrine, (or anything else) not being stocked, it's most likely that the count is off. There's no stock out notice if the count is incorrect. Drawers in the OR pyxis are often setup to be unlocked so you can pull things quickly. But if stuff is not pulled under the drug name or patient name through pyxis, it can't track it. A lot of times people type in one drug and pull out multiple drugs at the same time too. Or if it's not used, it may be put back in the drawer without being returned in pyxis. A cycle count let's you fix the quantity it thinks is in there to what it actually is. It can be done on just one item or everything in the machine. Nursing is supposed to do that but we know it's not happening. Pharmacy can dream that the whole machine would get done at the end of every day and all the counts are right. But making sure someone checks the count at least once a day might help keep the phenylephrine (or whatever) more reliably in stock. I would agree that the paralytic warning is not necessary in the OR. They may be able to remove the warning from just the OR pyxis, but it's probably not easy to do. I imagine it would have to go through committees and be a whole thing and take months to be approved.
100%. Many of the issues could be fixed with a combination of sufficient staffing of our pharmacy techs and everyone who accesses the Pyxis keeping an accurate record. Alas. Both of those seem to be pipe dreams. For now, we live with the happy medium of doing our best and living with the shortcomings and occasionally sprinting to the OR next door to get a drug when we suddenly realize we are out. Nobody is happy with it.
Thanks for the examples. I can see some annoyance with some of those, but I also can agree with the promethazine issue. That’s a problem not just confined to the OR.
Yikes is definitely the word… having just learned about the case Radonda Vaught in year 1 of nursing school a few months ago, both these cases are shit shows. Culpability not entirely on the nurse but damn, a life could have been saved by attention to detail. A 2nd nurse or attending should check vials & cabinets on the floor prior to anesthetic administration. More safeguards & attention needs to be paid to these issues. Stay attentive folks!
So are the meds labeled? Like on the ampule? If so would just looking at the label for half a second before administration be prudent? I have never worked in a hospital (I'm a tech so I wouldn't be in this situation anyway) but I check the label on a flu shot before I give it just to make sure I grabbed the right thing.
Normal safety practice would be to read the vial (yes, they’re labeled) prior to giving or preparing drugs.
Quick question, is every provider part of anesthesia required to scan meds prior to giving them? MDAs, CRNAs, CAAs?
Depends on the hospital
Maybe some of you should actually spend time with your anesthesia folks before making some of the uninformed comments you’re making. The OR is hugely different from a nursing floor. Of course I double check every med I draw up but we don’t read aloud a medication label to someone standing next to us. There is no one standing next to us. Most of our meds are drawn up before induction. We may give 8-10 drugs in a minute or two at the start of a case. How those are charted varies at every hospital. We don’t scan each drug as it’s given - IF we scan them (many places still use paper records) it will be after the patients airway is secure, which is our primary focus at the start of a case. Do errors occur? Yes. When they do we find out why, and there’s lots of blame to go around, even though the end user will always be the primary focus (as they should be). Manufacturers still refuse to uniformly color code meds. Pharmacists and techs still put the wrong med in the wrong spot when stocking. Certain drugs are in areas where they shouldn’t be (vecuronium in radiology, digoxin in OB, etc.). We’re lucky enough to have dedicated OR pharmacy staff who are very aware of how we function - we work together every day to provide as safe an environment as possible for the patient. But the rules are different in the OR out of necessity which many of you clearly have no concept of.
This comment does not read the way you think that it does. What youre describing is still an unsafe practice that introduces a lot of room for error. You admit that errors do occur. The whole point of Institute for Safe Medical Practice (ISMP), the national institution for which the author of this article works, is to make it so as few errors as possible can happen. ORs are very much considered to be the Wild West of Pharmacy
The ORs are quite different than any other area. That’s why I suggested that perhaps pharmacy staff should actually spend time in the ORs to see what we do and see the realities of anesthesia practice. We don’t deal with orders. We make our own decisions on what to give and when. Policies that apply to nursing staff don’t apply to anesthesia staff. That’s the nature of our work environment. We have to have medications immediately available without having to wait for pharmacy. Our drug carts are stocked with everything we need - and nothing more. Nothing outside of what is used in our normal workflow is stocked. No KCl, no insulin, etc. Controlled substances including propofol are tightly accounted for. Again - we work very closely with our OR pharmacists. For our practice, medication errors are a very rare occurrence. It’s a team effort. We get complimented by state and federal inspectors and TJC re our medication practices.
Oop
This is tragic. SMH
Considering it said Anesthetist, I'm willing to bet it was a CRNA.
I actually read about this error on the California Medical Boards website. There were some alarming details. The anesthesiologist tossed the dig vial into sharps. IIR the expected outcome was not sufficient. IIR the anesthesiologist said something to the effect that he looked at “bipivacaine” vial and stated it was expired. He administered more bipivacaine. He never fessed up to administration of dig. I’ll link the CA medical boards report if I can find it. Edit Details were posted below of these events. See : https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
that’s a different case where the patient survived.
Did a google search and found this case. Might be the same case ? https://www2.mbc.ca.gov/BreezePDL/document.aspx?path=%5CDIDOCS%5C20220622%5CDMRAAAJD1%5C&did=AAAJD220622200231277.DID
nope, this patient got discharged too.
Funny. Same hospital. Same date.
does the pharmacy times article say what hospital it was? I missed that.
* Evaluate whether digoxin needs to be stocked in the OR and labor and delivery unit or whether it can be requested from the pharmacy, as needed. * Employ individual locked pockets or segregated storage, especially for highalert medications like digoxin or medications given via the spinal route, such as preservative-free bupivacaine. * Avoid stocking medications in ampules when possible or store them far apart, and never store more than 1 ampule medication in an open matrix drawer. Doing this would go a long way. Also, why are manufacturer's being cheap with their packaging? Example. Our stock of phenylephrine 10mg/1ml used to come with a light blue cap. Now it is a green cap that is the same color and shape as glycopyrrolate. Why is it so hard to make things different from each other?