Fifteen years ago, an 11-year-old boy died mid-operation due to a blood pressure spike, causing his heart to stop. The cause? His anesthesiologist unknowingly administered the wrong drug. Ronald Litman, DO, a pediatric anesthesiologist at The Children's Hospital of Philadelphia, discusses this medical case and offers solutions on how to reduce anesthesiologist-related medication errors in an op-ed for The Inquirer.
Here are six things to know:
1. In the medical case, the boy's anesthesiologist gave him phenylephrine — a drug that quickly boosts blood pressure in severely ill patients — instead of the anti-nausea drug ondansetron. Both medications look similar and were stocked next to one another.
2. Litman notes anesthesiologists are responsible for prescribing, preparing and administering drugs in the operating room without assistance or technological support, sometimes during extremely stressful or chaotic situations.
3. He said wrong drug administration happens two ways: the anesthesiologist accidently chooses the wrong drug to administer, or the anesthesiologist administers the wrong syringe after the medication is removed from the vial
4. Hospitals must implement better drug administration protocols to prevent these errors from occurring, according to Mr. Litman.
"If operating rooms have not been equipped with the means to avoid these errors, patients have no choice but to rely on the anesthesiologist's vigilance to get it right, every time, many times a day," he wrote. "But, of course, human errors are inevitable. Therefore, the system of drug administration in the operating room must be engineered to prevent the error from occurring in the first place."
5. A mistaken-vial error can be avoided by supplying anesthesiologists with pre-filled syringes, which can be created by drug manufacturers, drug distributors or hospital pharmacy, according to Dr. Litman.
6. There is currently no system to physically stop mistaken-syringe errors from happening. However, strategies like bar-coding drug-filled syringes require anesthesiologists to scan the syringe, allowing a computer to confirm if the drug is correct and warn the anesthesiologist of any allergies or drug incompatibilities, according to Dr. Litman.
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