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
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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
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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.
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What could be done differently
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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
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CURRENT MEASURES
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ACTIONS
RECOMMENDED
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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