Dr Montosh Kumar Mondal
Assistant professor
Department of Anaesthesia Analgesia and Intensive care medicine
BSMMU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional patient or consumer Such events may be related to professional practice health care products procedures and systems including prescribing order communication product labeling packaging and nomenclature compounding dispensing distribution administration education monitoring And use
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
WHAT SORTWHAT SORT
OF ERRORS CAN OCCUR OF ERRORS CAN OCCUR
bullWrong drug
bull patient
bull Wrong route
bull Wrong dose
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Spinal anaesthesia is common and used for many surgical procedure
Accidental administration of wrong drug into the subarachnoid space may be associated with potential hazards
Confidential report in our country observe that accidental administration of wrong drug into the subarachnoid space is responsible for high morbidity and mortality
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Tranexamic acid
Atracurium
Neostigmine
Ephedrine hydrochloride
Magnesium sulphate
Among them tranexamic acid leading to fatal outcome
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional patient or consumer Such events may be related to professional practice health care products procedures and systems including prescribing order communication product labeling packaging and nomenclature compounding dispensing distribution administration education monitoring And use
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
WHAT SORTWHAT SORT
OF ERRORS CAN OCCUR OF ERRORS CAN OCCUR
bullWrong drug
bull patient
bull Wrong route
bull Wrong dose
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Spinal anaesthesia is common and used for many surgical procedure
Accidental administration of wrong drug into the subarachnoid space may be associated with potential hazards
Confidential report in our country observe that accidental administration of wrong drug into the subarachnoid space is responsible for high morbidity and mortality
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Tranexamic acid
Atracurium
Neostigmine
Ephedrine hydrochloride
Magnesium sulphate
Among them tranexamic acid leading to fatal outcome
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
WHAT SORTWHAT SORT
OF ERRORS CAN OCCUR OF ERRORS CAN OCCUR
bullWrong drug
bull patient
bull Wrong route
bull Wrong dose
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Spinal anaesthesia is common and used for many surgical procedure
Accidental administration of wrong drug into the subarachnoid space may be associated with potential hazards
Confidential report in our country observe that accidental administration of wrong drug into the subarachnoid space is responsible for high morbidity and mortality
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Tranexamic acid
Atracurium
Neostigmine
Ephedrine hydrochloride
Magnesium sulphate
Among them tranexamic acid leading to fatal outcome
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Spinal anaesthesia is common and used for many surgical procedure
Accidental administration of wrong drug into the subarachnoid space may be associated with potential hazards
Confidential report in our country observe that accidental administration of wrong drug into the subarachnoid space is responsible for high morbidity and mortality
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Tranexamic acid
Atracurium
Neostigmine
Ephedrine hydrochloride
Magnesium sulphate
Among them tranexamic acid leading to fatal outcome
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Tranexamic acid
Atracurium
Neostigmine
Ephedrine hydrochloride
Magnesium sulphate
Among them tranexamic acid leading to fatal outcome
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and
Anaesthethesiologist Attendant staff not adequately trained
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case report inadvertent intrathecal
injection of 80 mg tranexamic acid was
followed by severe pain in the back and
the gluteal region myoclonus on lower
extremities and agitation General
anesthesia was induced to complete
surgery At the end of anesthesia patient
developed polymyoclonus and seizures
needing supportive care of the
hemodynamic and respiratory systems
He developed ventricular tachycardia
treated with amiodarone infusion
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
The patientrsquos condition progressively
improved to full recovery 2 days after
Confusion between hyperbaric
bupivacaine and tranexamic acid was
due to similarities in appearance
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error
by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)
Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Year 2012 | Volume 56 | Issue 2 | Page 168170
Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah Department of Anaesthesia and Critical Care Smt K M Mehta and Smt G R Doshi Institute of Kidney Diseases and Research Center Dr H L Trivedi Institute of Transplantation Sciences Civil Hospital Campus Asarwa Ahmedabad Gujarat India
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review
U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
SUMMARY
Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
This report relates how tracurium was given by mistake intrathecally during spinal anesthesia to a 38-year-old woman who was a candidate for abdominal hysterectomy When no analgesia was observed the mistake in giving the injection was understood She was evaluated postoperatively by train of four ratio measuring her breathing rate eye opening and protruding of tongue at one two twenty-four and forty-eight hours and then at one and two weeks with the final evaluation the following month The patient had normal timings during the operation and postoperation periods and no abnormal findings were observed through the first month
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month
That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs
(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section
SAB was given
No sensory or motor block were noted
Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine
Again SAB was given with 05 bupivacaine
Operation started
After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion
Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg
For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given
Patient was intubated muscle relaxant was given and put on ventilator
With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Laboratory investigation- selectrolytes glucose calcium creatinine were normal
Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT
Urine output gradually declined
BP gradually declined
Pulse rate gradually increased
ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15
Inj NaHCo3 was given
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient developed high grade temperature
Patient developed VT Hypotension and hypoxia
Patient developed cardiac arrest
CPR given but could not be revived
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
TXA is a synthetic analog of the amino acid lysine
bullIt is used to treat or prevent excessive blood loss during
surgery and in various other medical conditions
bull It is an antifibrinolytic that competitively inhibits the
activation of plasminogen to plasmin by binding to specific
sites of both plasminogen and plasmin a molecule
responsible for the degradation of fibrin a protein that forms
the framework of blood clots
bullIts use in humans is generally well tolerated
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions
Use of tranexamic acid has a potential risk of thrombosis
Neurotoxicity and seizures have been reported in animal studies
Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Generalized convulsions
Refractory ventricular tachycardia and fibrilation
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Antagonist action at GABA receptors results in lowering of seizure threshold
Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow
Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Administration of anticonvulsants
Intensive hemodynamic monitoring
Antiarrhythmic drug
CSF lavage
CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All accident occurred due to the same appearance of the ampoules
Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote
Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Patient Safety Update - The
Royal College of
Anaesthetists
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012
bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or
dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o
administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in
drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer
them bull Drugs should be colour coded by class according to national or international
standards bull Coding by syringe position size or needle on the syringe could be used
Medication Errors
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
DrJEdward Johnson
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Safety of the Anaesthetist
Safety of the Surgeon
Safety of the Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
THE 5-RrsquoS
World Health Organization WHO Patient Safety Curriculum Guide
bull Right Drug
bull Right Route
bull Right Time
bull Right Dose
bull Right Patient
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
All drugs should be clearly labelled
The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected
Ideally drugs should be drawn up and labelled by the anaesthetist who administers them
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
PDF compression OCR web optimization using a watermarked evaluation copy of CVISION PDFCompressor
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