Reliable Acute Care Medicine

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