Near-miss Injection of an Anesthetic Agent into a Cerebrospinal Fluid External Ventricular Drain: Special Report

Abstract

Human error has been increasingly recognized as a cause of patient morbidity and mortality. One method of error prevention is the reporting of a near-miss event. We report that intravenous anesthetic agents were nearly injected into the external ventricular drainage (EVD) of a patient during an emergency shunt procedure. A 3-year-old male patient with multiple cerebrospinal fluid shunts and shunt infection had an external ventricular drain catheter tunneled to exit just inferior to the left clavicle during a previous procedure. The exit site was covered by an occlusive dressing. This particular system, the Codman external drainage system II collection bag and tubing set (Codman & Shurtleff, Inc., Raynham, MA), contains two access ports (a three-way stoppered port and an angled rubber stoppered injection port). At induction of anesthesia, the EVD system was mistaken for a central venous line and was nearly injected with propofol and rocuronium. Fortunately, the error was quickly recognized and the patient came to no harm. A modified EVD system has recently been released that does not include the three-way port, and features an embedded bright green stripe in the tubing to distinguish it from intravenous tubing. We recommend using caution when tunneling EVDs to sites that might be confused with central venous access sites. EVD system tubing should be designed so it can be easily distinguished from intravenous tubing, and it should be clearly labeled as an EVD line.