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- Phil B Tsai and Michael W Bergin.
- From the Division of Pediatric Anesthesia, Department of Anesthesiology, Harbor-UCLA Medical Center, Torrance, California.
- A A Pract. 2020 Apr 1; 14 (6): e01179.
AbstractVerbal orders in the operating room between the surgeon and circulating nurse are prevalent at many institutions. We present a case in which a communication breakdown involving a verbal order resulted in the patient receiving an excessively high dose of epinephrine via subcuticular infiltration. The overdose was quickly identified by an increase in T-wave amplitude on electrocardiogram (ECG). The hemodynamic changes were treated, and the patient suffered no long-term sequelae. This report emphasizes the need to have strategies in place to prevent medication errors.
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