Reliable Acute Care Medicine

Abstract

A patient receives a thoracic epidural catheter for postoperative pain relief. On arrival at the PACU, the epidural catheter is connected to a delivery pump containing a dilute mixture of local anesthetic and opioid (PCEA pump; Patient-Controlled Epidural Analgesia). Satisfactory epidural blockage is established. Several hours after the operation, the patient is transferred to a general ward with stable vital signs and with efficient pain control. In the course of the next hours, the line from the PCEA pump is disconnected from the epidural catheter for reasons unknown and improperly connected to the central i.v. line. This error is facilitated by the nurse’s lack of familiarity with the different techniques of pain relief and the fact that both lines are from the same manufacturer and are similar in appearance. As a result of the misconnection, the pump infuses the local anesthetic and the opioid intravenously. Due to insufficient pain reduction, the patient requests PCEA boli more frequently; however, instead of relieving the pain, the requested boli now lead to short periods of dizziness. The incident is detected before toxic plasma levels of the local anesthetic are reached and thus has no long-term consequences for the patient. Because the hospital has established an Incident-Reporting System (IRS), the reporting physician is able to notice that two similar incidents had occurred within the past months. Because all three incidents reveal a similar pattern, a systemic problem seems much more likely than an isolated personal failure. The physician directs the attention of the hospital’s risk management to these incidents. The root cause analysis results in several practical steps to solve the problem. The knowledge gained from these incidents is fed back into the system by creating guidelines and additional teaching opportunities (e.g., morbidity and mortality conference, simulation-based training).