Abstract
Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. To highlight the significance of medication errors in our practice and to discuss the best methods of prevention. A report of two cases of errors in the administration of drugs during the conduct of anaesthesia. The subsequent management of the cases is presented, and the findings from the literature are discussed. In case 1, an adult male presented for herniorrhaphy and after induction with propofol 1mg/kg intravenously, Pancuronium bromide injection 4 mg was administered intravenously, in the place of suxamethonium chloride injection. In case 2, For induction of anaesthesia, 100mg of thiopentone sodium was administered in place of 25mg of the same drug because Thiopentone 1 gm vial was mistaken for Thiopentone 500 mg vial in a 2 year old girl. In both cases, the errors were detected early and there were no adverse sequelae. Medication errors are a potential source of iatrogenic harm to patients undergoing anaesthesia. Strict adherence to principles as well as constant vigilance would minimize this problem.
Highlights
Case reportsCase 1 B.M a 50 year old male farmer presenting with a right inguino-scrotal hernia for herniorrhaphy (RISH)
Mistakes in the identification and administration of drugs may be fatal
Case 1 B.M a 50 year old male farmer presenting with a right inguino-scrotal hernia for herniorrhaphy (RISH)
Summary
Case 1 B.M a 50 year old male farmer presenting with a right inguino-scrotal hernia for herniorrhaphy (RISH). Endotracheal intubation was to be facilitated by suxamethonium 0.5mg/kg intravenously but the anaesthesia practitioner who was assisting withdrew pancuronium bromide 4mg and injected intravenously. At the end of surgery, residual paralysis was reversed with neostigmine and atropine and the patient was extubated. He recovered fully with no adverse sequelae (see figure 1). At induction of anaesthesia 100mg of thiopentone sodium was administered in place of 25mg of the same drug! Suxamethonium chloride 12.5mg I.V was given and the child was intubated with a size 2.5mm ETT. All the drugs drawn were crosschecked only to discover that the anaesthetist had mixed 1gm of thiopentone with 10ml and thereafter had withdrawn 1ml (100mg) and injected instead of the 25mg that was supposed to be administered. All the drugs drawn were crosschecked only to discover that the anaesthetist had mixed 1gm of thiopentone with 10ml and thereafter had withdrawn 1ml (100mg) and injected instead of the 25mg that was supposed to be administered. (See figure 2) IPPV was continued and monitoring, there were no untoward sequelae in both cases
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