The Nature of Error

Abstract

An anesthesia resident physician in his second year of training anesthetizes a 76-year-old patient scheduled for a laryngectomy and bilateral neck dissection. The medical history reveals coronary artery disease and liver cirrhosis. As a result of the associated coagulopathy, the surgeon has difficulty achieving adequate hemostasis and therefore repeatedly applies epinephrine-soaked swabs to the surgical site. The undiluted epinephrine is rapidly absorbed into circulation and causes sinus tachycardia and polymorphic premature ventricular contractions. Unaware of the surgeon’s use of undiluted epinephrine, the resident does not attribute the PVCs to the hemostatic treatment and hence does not urge the surgeon to stop the application. Instead, he decides to treat the arrhythmia with an ampule of lidocaine. Distracted by the ECG, the anesthetist does not pay close attention and mistakenly uses an ampule of metoprolol (a β-blocker) instead of the intended dose of lidocaine 2%. This drug error is facilitated by the fact that both ampules are adjacent to each other in the anesthesia cart and have similar looking labels. The bolus of the β-blocker leads to cardiac arrest. Immediate CPR is started. After calling the attending anesthesiologist to the operating room, the patient is successfully resuscitated. The patient is discharged from ICU the following day without any neurological deficits.