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A1279
October 26, 2005 9:00:00 AM - 11:00:00 AM Hall C4 |
| Toxidromes and Medication Errors from the Supervisor's Perspective |
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Elizabeth H. Sinz, M.D., W. Bosseau Murray, M.B., Ch.B., Steve J. Kimatian, M.D., Jody L. Henry, B.S. Department of Anesthesiology, Penn State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States |
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Introduction Toxidrome is a term that signifies the clinical symptom complexes of drugs. The thought process for treating a patient who has had an unknown toxin exposure is similar to the approach one takes for treating a medication error in the hospital, a situation in which supervising anesthesiologists may find themselves. Often, it is essential for the offending agent to be identified rapidly to avoid patient injury. Methods Using a simulated patient care environment we demonstrated four scenarios where the wrong medication or wrong dose of medication was accidentally administered. Real cases were chosen to demonstrate different types of errors. Trainees observed the events of the case and then were asked to assume the role of attending anesthesiologist called to assist with the problem. A well-respected attending anesthesiologist played the role of primary provider who makes the error. Case #1: 53 yo male trauma patient with severe upper extremity laceration and associated hemorrhage requires urgent assessment and treatment in the OR. He is extremely anxious but becomes unconscious with midazolam. Point: Wrong concentration of medication. Patient given 15 mg instead of 3 mg midazolam. Case #2: 35 yo female for gastric bypass after full bowel preparation. Prolonged hypotension after induction is completely refractory to pressors despite reasonable volume loading. Point: Medication mixed incorrectly. Bag labeled “phenylephrine” had no medication added. Error #3: 71 yo male for urgent suprapubic catheter and cystoscopy for urinary retention. Pt takes an unknown antihypertensive drug. He develops asystole when given β -blocker. Point: Drug interactions. Asystole due to combination of β-blocker and Ca-channel blocker. Error #4: 51 yo male under general anesthesia is breathing spontaneously at the end of the case, so the resident gives the reversal agent. When time for extubation, the patient is not breathing. Point: Drug swap. Additional muscle relaxant given instead of reversal agent. ResultsThe residents rated this session very highly overall. (4.7 ± 0.11 (Avg ± SE) on 5-point scale) They gave similar scores for realism, quality, and goals of the session. Comments included statements that the session made them more aware of medication errors, made them feel like they were really dealing with the complication, and that there should be more simulation sessions such as this one. This session allows trainees to learn from errors made by others so that they may avoid making similar mistakes in actual practice. Anesthesiology 2005; 103: A1279 |