EMERGENCY CHECK
Review all ampoules/syringes/bags/burettes/diluents/ cassettes
Review all drug and cannulae labels
Systematically review all vascular access equipment, working from fluid source,
via the cannula/skin interface
to the tip of the cannula
Check that vehicles/dilutions/rates/routes are correct
Correlate doses with effects
If you have any doubts about the contents of a syringe or infusion discard and
prepare a new solution.
ALWAYS CONSIDER
Drug administration problems may be interrelated with vascular access problems
(4-8)Wrong patient
Wrong drug (3) (6)
Ampoule or syringe swap
Known allergy
Right drug (3) (6)
Wrong dose/rate
Wrong diluent/dilution
Wrong time
Wrong route/site
Failure of intended delivery (4) (5)
Malpositioned cannula tip (4)
Bag/syringe/burette empty
Cannula disconnected/blocked/kinked
Line disconnected/blocked/kinked
Back flow (up a "Y piece")
Unintended delivery (6)
Drug flushed from dead space of IV line or cannula (7)
Drip/pump delivering drug inadvertently (8)
"Flushing" syringe containing drug
Someone else giving the drug (3)
Check for any unrecognised cannulae in situ (5)
BEWARE
Any syringe containing relaxant
Haematoma/extravasation
Inadvertent intra-arterial placement
Pneumothorax, haemothorax, hydrothorax
Nerve damage
Dysrhythmias (cannula tip in heart)
Cannula dead space
NOTES:
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The figures reported here are based on an analysis of 1199 drug and 128 access
problems reported to the first 4000 AIMS anaesthesia incidents
(1) Problems with drug administration thus comprised 30% of all 4000
reports to AIMS. The incidence of errors rises markedly with polypharmacy.
(2) major morbidity in 25% of drug reports. death in 1.25%.
(3) Contributing factors:
error of judgement 13%
inattention 11%
haste 10%
communication problem 9%
drug label problem 5%
fatigue 3%
(4) Approach the diagnosis of vascular access problems from a
"geographical perspective":
infusion device/fluid
fluid line/equipment
line dead space
catheter/skin interface
peripheral vascular tree
central vascular space
staff and environment
51% of the 128 cases involved a fault at the catheter/skin interface. In 15%
of these the cannula was inserted by
someone other than the anaesthesiologist.
18% involved central venous lines.
(5) Incorrect manufacture or assembly of arterial/central/peripheral lines - 8%
Disconnection resulting in unrecognised blood loss - 6%
(6) Errors included:
Connection of wrong infusion pump/fluid - 3%
Over/under dosage fluid/drugs - 2% (especially
adrenalin
Drug precipitation in the line dead space - 2%
Anaphylaxis to infusions - 2%
(7) Suxamethonium remaining in the dead space caused late paralysis upon
subsequent line flushing in 6 case reports
(8) Unrecognised cannulae may be the source of disconnections, or be the route
of an unknown delivery of drugs/fluids
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