Article Notes
- Similar drug ampoule appearance.
- Drug storage problems.
- Carefully read the ampoule before drawing up, and the syringe label before administering.
- Label syringes!
- Check labels with a second person or a device.
- Use non–luer lock connectors on all neuraxial catheters & devices.
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This quote is usually attributed to the Greek poet Archilochus, over 2,500 years ago... though today popularised by the US Navy SEALs! (and perhaps a few medical simulation specialists 😉) ↩
Another useful review of neuraxial tranexamic acid, although not indexed by pubmed. Full-text below:
Gupta et al., Tranexamic acid: Beware of anaesthetic misadventures, J Obst Anaesth Crit Care 2018.
Daniel Jolley
A systematic review of 29 published cases of neuraxial obstetric drug errors, including four maternal deaths related to inadvertent intrathecall tranexamic acid.
What’s the first warning sign of an intrathecal drug error?
Block failure was the most frequent reported complication.
What were the most common human factors causing the errors?
Any recommendations to reduce the risk of drug errors?
Daniel Jolley
A neat little study...
Gurus and team showed improvement in assertiveness and 'speaking up' behaviour among junior anaesthesia trainees, during a simulation workshop after exposure to a didactic session on speaking up behaviour – when compared to a control simulation group who did not receive the didactic session. (n=22)
The take-home message
There is likely benefit to explicitly discussing the issue of, and most importantly techniques for, speaking up when anaesthesia trainees witness management errors or oversights.
The one short-coming
The effects were only observed in a simulation environment, and while probably applicable to the more-consequential real world, as with much simulation research we are often dependent on surrogate markers of performance improvement.
Nonetheless, "we don't rise to the level of our expectations, we fall to the level of our training",1 right?
Daniel Jolley