Anaes Cases · Patient safety, human factors & CRM
The drug error and the root-cause analysis
The long case — the drug-swap error. The systems (the Swiss cheese) analysis; the latent conditions (the syringe labelling, the storage, the crisis, the time pressure); the active failure (the slip); the root-cause and the systems redesign (the standardised labels, the colour-coding, the read-back, the separation); the just culture; and the second-victim support.
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During a prolonged laparotomy, the patient develops the bradycardia (the heart rate of 35). The anaesthetist, under the time pressure, reaches for the 'atropine' syringe and administers it; the patient develops the severe hypertension (240/130) and the ST depression. The syringe is found to have been the adrenaline (the 1:10 000) that was drawn up and the mis-labelled. The patient is stabilised and recovers without the infarction. Discuss the systems analysis and the prevention.[42265304]
References4ShowHide
- [2]Wen L, et al. Crisis resource management in nonoperating room anesthesia. Curr Opin Anaesthesiol, 2026.PMID 42228455
- [3]Paterson E, et al. Occupational stress in anaesthetists: a narrative review of psychosocial risk management using a human factors systems approach. Br J Anaesth, 2026.PMID 42156312
- [4]Morato O, et al. Surgeons' stress after surgical mortality. Langenbecks Arch Surg, 2026.PMID 42265303
- [42265304]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.