Orser B A, Oxorn D C
Department of Anaesthesia, Sunnybrook Health Science Centre, Toronto, Ontario, Canada.
Can J Anaesth. 1994 Feb;41(2):120-4. doi: 10.1007/BF03009804.
A medication error caused a near fatal cardiac arrest in a previously healthy patient undergoing elective surgery. Inadvertent epinephrine injection induced ventricular dysrhythmias, hypertension, hypotension and pulmonary oedema. The case was investigated using critical-incident technique and was reviewed by the Risk Management Team of the Department of Anaesthesia. The purpose of this report is to present the recommendations resulting from the investigation. These include: improved resident training in intravenous drug management, the use of anaesthetic drug ampoules with distinct labels, and the development of a standardized colour code system for labels on anaesthetic drug ampoules. Furthermore, it is recommended that all anaesthetic drug errors be reported to the Canadian agencies responsible for drug packaging in order to identify patterns in anaesthetic drug errors, and to facilitate the implementation of effective drug identification systems.
一起用药错误导致一名接受择期手术的原本健康的患者发生了近乎致命的心脏骤停。意外注射肾上腺素引发了室性心律失常、高血压、低血压和肺水肿。该病例采用关键事件技术进行了调查，并由麻醉科风险管理团队进行了审查。本报告的目的是呈现调查得出的建议。这些建议包括：改进住院医师在静脉药物管理方面的培训，使用带有明显标签的麻醉药物安瓿，以及开发麻醉药物安瓿标签的标准化颜色编码系统。此外，建议将所有麻醉药物错误报告给加拿大负责药物包装的机构，以便识别麻醉药物错误的模式，并促进有效药物识别系统的实施。
