https://psnet.ahrq.gov/web-mm/saline-flush-leads-a…
SALINE FLUSH LEADS TO
ACUTE PARALYSIS OF
AN AWAKE PATIENT
ROBERT SCOTT KRISS, DO
Case Study 3:
SALINE FLUSH LEADS TO ACUTE
PARALYSIS OF AN AWAKE PATIENT
2
CASE SUMMARY (½)
The Patient:
•
48-year-old man with colon cancer.
•
In for laparotomy (surgical cut into abdominal
cavity) & sigmoid colectomy (removal of last
What Happened:
•
An IV cannula (inserted in the arm or hand) was
inserted for pre-op fluids.
•
The Anesthesiology resident assigned to the
case flushed the patient’s IV cannula to ensure it was
section of colon).
functional.
•
The Anesthesiology department had run out of bright
red labels for rocuronium (a strong muscle relaxant).
Presentation title
CASE SUMMARY (2/2)
•
Syringes containing rocuronium were labelled with handwritten labels.
•
Immediately after IV flush with a syringe labelled as “0.9% saline”, the patient became unresponsive &
immobile.
•
The patient was then intubated, the operation was cancelled, and the patient was transferred to the ICU both
ventilated & sedated.
•
After an hour in the ICU & muscle relaxant reversal medication was given, the patient was extubated & stable.
•
The patient was scheduled for close follow-ups to assess potential complication both physically & psychologically
3
Presentation title
4
COMPROMISED QUALITY OF CARE
ADVERSE DRUG EVENT
DUE TO A MISLABELING
SYRINGE SWAP.
THE PATIENT’S SURGERY
WAS DELAYED DUE THE
INCIDENT.
THE PATIENT RECALLS
FEELING “PARALYZED”
UPON RECEIVING IV
FLUIDS.
POTENTIAL FOR PTSD,
SEVERE ANXIETY, &
OTHER PSYCHOLOGICAL
ISSUES.
Presentation title
What could be done differently
5
Presentation title
6
FUTURE PREVENTION
•
Preprinting labels and color-coding systems
•
Enhancing education and training on
medication safety for all healthcare providers
•
Introduction of barcode or QR code systems for
medication verification before administration
Presentation title
7
CURRENT MEASURES
Presentation title
ACTIONS
RECOMMENDED
8
• Strict adherence to pre-printed labels
• Implement color designated labels
• Use bar codes or QR codes on printed
labels
• Never combine syringes prior to labeling
THANK
YOU
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