SYRINGE SWAP: WHAT WAS IN THAT SYRINGE I JUST INJECTED INTO MY PATIENT?

Clinical Case for Discussion: A 70-year-old man presents for an elective descending colectomy.  Immediately prior to induction of anesthesia, the patient’s heart rate drops to 48 beats per minute.  You reach for a vial of atropine 0.4 mg, but grab the wrong vial by mistake and administer 1 mg of IV epinephrine.  His heart rate climbs to 175 beats per minute, and he cries out, “My head is exploding.”  What do you do?

Discussion:  Consider this math problem:  Assume you’ll practice anesthesia for 25 years, performing 700 anesthetics per year.  If on the average you inject 10 different drugs into each patient, that equals a total of 1,750,000 drugs you will personally inject in your career.  What are the odds that you’ll make a mistake and pick up a wrong ampoule or wrong syringe at least once during those nearly two million repetitions?  I’d say the odds are 100%.  You’re good, but you’re human.

Human error is a topic of intense scrutiny in medicine.  In 1999, the Institute of Medicine released its landmark publication To Err is Human:  Building a Safer Health Care System, which reported that 44,000 to 98,000 hospitalized patients in the United States died every year due to medical errors.  This publication stated that, “high error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments.”

Miller’s Anesthesia (6th Edition, 2005, Chapter 83) states that, “errors in executing a task are termed slips, as distinguished from errors in deciding what to do, which are termed mistakes.  Slips are actions that do not occur as planned, such as turning wrong switch or making a syringe swap.”

Anesthesiologists are unique among medical doctors in that we routinely handle and inject medications ourselves, rather than writing orders for nurses to carry out. While this direct involvement has the advantages of efficiency and flexibility, it carries the risk of human error.  While multi-tasking (watching monitors, performing hands-on procedures, and filling out medical records), anesthesiologists are vulnerable to having their attention distracted.

The issue of inadvertent syringe-swap or ampoule-swap has been discussed in the medical literature. Currie, et al reported 144 incidents where the wrong drug was nearly or actually administered by an anesthesiologist (The Australian Incident Monitoring Study.  The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports, Anaesth Intensive Care. 1993 Oct;21(5):596-601.) In 81% of the 144 incidents the wrong drug was actually given. In over half of these occurrences, the syringes were of the same size, and they were correctly labeled. The most common error was giving the wrong drug from a correctly labeled syringe. The most common drug involved was a muscle relaxant in both ampoule and syringe incidents.  Factors which contributed significantly to the incidents were similar appearance, inattention and haste.  The only significant factor which minimized the outcome was rechecking of the syringe or drug ampoule before giving the drug. Strategies suggested to address the wrong drug problem include education of staff about the nature of the problem and the mechanisms involved; color coding of selected drug classes for both ampoules and syringes; the use of standardized drug storage, layout and selection protocols; having a drawing up and labeling convention; and the use of checking protocols.

In a Japanese study, Irita, et al reported the incidence of critical incidents due to drug administration error as 18.27/100,000 anesthetics. (Critical incidents due to drug administration error in the operating room: an analysis of 4,291,925 anesthetics over a 4 year period, Masui. 2004 May;53(5):577-84.) Cardiac arrest occurred in 2.21 patients per 100,000 anesthetics. Causes of these critical incidents were as follows: overdose or selection error involving non-anesthetic drugs, 42.1%; overdose of anesthetics, 28.7%; inadvertent high spinal anesthesia, 17.9%; local anesthetic intoxication, 6.4%; ampoule or syringe swap, 4.3%; blood mismatch, 0.6%. Ampoule or syringe swap did not lead to any fatalities. 88 percent of ampoule or syringe swap occurred in patients with American Society of Anesthesiologists-Physical Status 1 or 2, who did not seem to require complex anesthetic management.  The authors concluded that bar-coding technology might be useful in preventing drug administration error.

In a confidential survey, private practice anesthesiologist colleagues of mine admitted the following significant syringe or ampoule swaps during their careers:  pancuronium instead of neostigmine, mivicurium instead of midazolam, atracurium instead of atropine, epinephrine instead of naloxone, epinephrine instead of ephedrine, and metoclopramide instead of neostigmine.

Have you ever administered the wrong drug to a patient?  If you did, did you fess up and write the wrong drug on your anesthetic record, or did you merely treat the consequences of the wrong drug (if any) and tell no one?  I suspect the true incidence of syringe and ampoule swap is unknown, and is indeed a higher number than reported in the medical literature.  Because of the risk of being sued and/or the risk of becoming the focus of peer review criticism, I believe many practitioners avoid reporting a drug administration error unless they can’t avoid reporting it (e.g. their patient is paralyzed for an extra three hours because of an unintended dose of pancuronium).

Future application of bar-coding technology for anesthesiologists in the operating room to assist in pharmacy billing of drug ampoules may serve to improve the accuracy of proper drug administration as well as improve accuracy of wrong drug reporting.  In the meantime, I’d advise leaving a drug in the ampoule until you need to use it, and then double-checking the ampoule twice before administering the drug.

Let’s turn the discussion to our case study patient who received 1 mg of epinephrine instead of 0.4 mg of atropine.  You choose to treat his elevated heart rate of 175 beats per minute with two doses of esmolol 50 mg each.  The heart rate drops to 110, but the blood pressure rises to 255/150, the patient develops acute pulmonary edema, has a grand mal seizure followed in minutes by ventricular fibrillation, and dies.

In a parallel universe, you’re aware that treating epinephrine overdose with a beta-blocker alone can result in unopposed alpha-adrenergic stimulation, marked vasoconstriction, and hypertension.  You begin combined alpha and beta-blockade with titrated doses of labetalol, 10 mg each, until the patient’s heart rate drops to 98 and his blood pressure drops to 150/85.  You cancel the elective surgery and report the mishap to your Quality Assurance/Peer Review committee.  Rather than condemning you, the QA committee works with the pharmacy to assure that dangerous medications such as epinephrine and phenylephrine are in ampoules and locations dissimilar to other medications.  The QA committee works with the administration and pharmacy to investigate bar code reading of all administered drugs in the operating room.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:

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Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.

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The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:

BOOK REVIEW “THE DOCTOR AND MR. DYLAN”

This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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One thought on “SYRINGE SWAP: WHAT WAS IN THAT SYRINGE I JUST INJECTED INTO MY PATIENT?

  1. Dear Sirs,

    I would like to ask you for your help. I underwent a transtympanic drenaige in my left ear the 19th of Novembre 2010, during the operation I felt that the anesthesia went into the ear, I could feel much pain during the whole operation and since then I have tinnitus, I am vomiting many days, and I am feeling nervous impulses in the left side of my body, and these days has worsened since I have numbness of my left arm and left leg and this numbness is worse when I go to be. It is starting to happen more often and I am worried.

    Due to the fact that my tinnitus was so unberable and I had never had that before the operation I went to urgencies at the hospital many times, and my ENT decided to take out the tiny tube or drainage ( which was placed to free some pressure in my left ear). My ENT told me that there had been ventilation enough and that the my body was rejecting it, so he decided to take it away. But the tinnitus didn’t go away, it has been 3 months and the tinnitus a strong buzzing and a whistle are still there, and besides I have that numbness which I didn’t have before and it is as if I am losing strenght in the muscles of my left side of the body. I am scared that the anesthetic is causing damages in my brain or the Nervous Central System. Could you please tell me if my symptoms could be due to the local anesthesia and if there are any risks when it is injected by mistake into the ear.

    Please I beg you to help me, I am worried about the tinnitus and numbness I am afraid that it is due to the local anesthesia injected in my ear by mistake, and I don’t know what to do. Because I went to my family doctor and told her that in the operation they had injected me the anesthesia in the ear, and she said that probably in some months would vanish, but she didn’t tell me the damage it could cause.

    Thank you so much for your help.

    AM

    Like

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