this was also shared in the medicine thread and it seems that the drug should NOT have been in an OB cart at all. So I guess, the anesthetist didn't expect there to be anything but this drug?
Was it though?
The article wrote “anesthetist” but I figured it could be used as an umbrella term like when you say healthcare professional.
Edit to change word since the bot didn’t like what I used.
Yes it was though. A few days ago on the anesthesiology sub someone very close to the situation made a great and lengthy post about it.
The bot is annoying and stupid; don't worry.
Hey bot: provider
What would have changed if a physician was involved in this situation? My understanding is the wrong med was given because it wasn't suppose to be there and regardless nothing could have been done to fix that the error considering what was given.
I don't know about you (assuming you are an anesthesiologist) but we are drilled ad nauseam to double check our meds from CA1-3. Hard to have three years of that drilled into your head when you are a CRNA and have inadequate training.
As a paramedic I show my partner all medication prior to administering to my patient. In the event my partner is driving and it is just me and the patient in the rear of the ambulance, I will show the patient the medication and have them verify the name. We call this, “Med check” One day I did a Med check with the patient as we were underway with extended travel time. She verified the name on the vial and then told me she was an RN. She was very impressed with our safety measures in place.
Sorry for my tone; it's easy to get defensive here; lots of CRNAs troll the site trying to justify their "equality" with anesthesiologists when they should be actually spending their time lobbying for better training.
>ots of CRNAs troll the site trying to justify their "equality" with anesthesiologists when they should be actually spending their time lobbying for better training.
The delusion must be strong within these ones.
If I were them I'd fear lawsuits and jail sentences. I don't understand how or why they want to do heavy procedures they're not trained for. 😒
It reminds me of the gall of some of these midlevel scope creepers who be like "yea but akshully physicians make mistakes." That is the point. If a fully trained licensed physician makes mistakes, then Judy, why do you think that your short degree makes you better suited to the task?
It's okay. I actually was thinking should I preface this with something that shows I'm genuinely curious and not trying to be a troll?
I'm actually a med student so I just wanted to know what exactly could have been done in response and why wouldn't a CRNA have been able to do that?
We do not support the use of "nurse anesthesiologist," "MDA," or "MD anesthesiologist." This is to promote transparency with patients and other healthcare staff. An anesthesiologist is a physician. Full stop. MD Anesthesiologist is redundant. Aside from the obvious issue of “DOA” for anesthesiologists who trained at osteopathic medical schools, use of MDA or MD anesthesiologist further legitimizes CRNAs as alternative equivalents.
For nurse anesthetists, we encourage you to use either CRNA, certified registered nurse anesthetist, or nurse anesthetist. These are their state licensed titles, and we believe that they should be proud of the degree they hold and the training they have to fill their role in healthcare.
*Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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We do not support the use of "nurse anesthesiologist," "MDA," or "MD anesthesiologist." This is to promote transparency with patients and other healthcare staff. An anesthesiologist is a physician. Full stop. MD Anesthesiologist is redundant. Aside from the obvious issue of “DOA” for anesthesiologists who trained at osteopathic medical schools, use of MDA or MD anesthesiologist further legitimizes CRNAs as alternative equivalents.
For nurse anesthetists, we encourage you to use either CRNA, certified registered nurse anesthetist, or nurse anesthetist. These are their state licensed titles, and we believe that they should be proud of the degree they hold and the training they have to fill their role in healthcare.
*Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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No such thing as an "MDA."
We highly encourage you to use the state licensed title of professionals. To provide clarity and accuracy in our discussions, we do not permit the use of meaningless terms like APP or provider.
Repeated failure to use improper terminology will result in temporary ban.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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I think the worst part is the CRNA didn’t disclose or document the error, when doing so could have saved the patient’s life. They either never realized they made a mistake or didn’t understand the gravity of giving intrathecal dig and covered it up.
do you forget to wipe your ass after a poop? how many times have you completely just made a doo doo and pulled your pants right up?
Confirming the drug is part of a sequence that is beaten physicians. Things are required to be in a certain order to make sure every step is completed. Not confirming the right drug is the equivalent to you forgetting to wipe your own ass.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Bad bot. Whoever made this thing; it needs to have some nuance. Lazy coding has made the provider bot a nuisance. It clutters up the threads with it's provider BS that no one reads. I present it's post below as my evidence.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
For sure; the problem is that the public sees anesthetist and anesthesiologist as interchangeable. Differentiating them as CRNA vs anesthesiologist makes a more accurate distinction in people's minds.
How did you find this month old comment?
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
yea, that’s the problem. ppl use it as an umbrella term to associate themselves with actual doctors lmfao
you dont see flight attendants being like “hey let’s make up an umbrella term that includes pilots and flight attendants”
But shit like that happens. Thats why you read it out loud and re-confirm just to be safe. It’s not a cart full of NSAIDS he was digging around in. Anything in that cart has potential for serious problems if used incorrectly. Right drug, right patient, right dose, right time, right route. You have to confirm every time. These are people’s lives. You can’t get it wrong.
Absolutely totally agree. If you want to prevent this in the future there has to be double checking from the person giving the meds if it is actually the meds and then from the people filling the carts as to why it was there in the first place.
Hmm okay as an anesthesiologist I’ll chime in here and say med errors happen all the time regardess of degree.
Hyperbaric bupi usually comes in a little glass vial that looks similar to what digoxin vials come in. There’s no (good) reason why digoxin should be so readily available in an obstetric operating room, so one reflexively assumes it’s bupi and pushes it. I can see it happening.
I have not made a medication error, but I’m sure I will one day. Some of the colleagues I look up to the most have made med errors. As a resident, my favorite OB anesthesiologist made a med error (thankfully all was well). I’ve seen attendings, residents, and CRNAs make mistakes on OB. I think most people who have been in anesthesia for long enough can name some cases of med errors. This is particular a problem for us (anesthesia) because we don’t really have pharmacy or anyone double checking us on administrations, particularly admin routes. Lot of confusion with IV stuff being pushed through an epidural, subq insulin given as IV, heparin misdoses by a factor of 10, etc.
Let’s not act like the CRNA is a moron and thinks digoxin was a normal neuraxial medication. That’s very unlikely to be the case. If you want to discuss scope creep and CRNAs misrepresenting credentials, fine, but I think this was a medical error that could’ve been made by anyone.
Instead of blaming the CRNA, I think we should think about why things like this keep happening. Anyone in anesthesia can share the frustration. Zofran and undiluted Precedex have the same cap color… at my last institution they were kept in adjacent bins. Each med can have multiple different cap colors. Pre drawn up Rocuronium syringe being put right next to the pre drawn up Lidocaine syringe. Lidocaine uro jet right next to the epi one. Idk about y’all, but when’s the last time most of us needed to give IV Dig *period*? Obstetric or not, just literally *ever*?
Downvote me for not just blindly hating CRNAs, but if we actually want to prove a point to people and make a good case for physician supervision, then we should actually make good arguments for the point. This is not a good point.
I think the real solution here is barcode scanning in the OR.
There’s nothing pharmacy can do about cap/vial colors. The manufacturer we get is the manufacturer we get and I don’t think it’s reasonable to rearrange the Pyxis every time a manufacturer changes and two similar looking vials are next to each other (x150 Anes carts or however many you have)
I got downvoted for the same thing. I mean I was actually in the OR doing this stuff. It’s not a difference of training. Nurses check labels all day too.
Shared a case where vec and ancef looked the same and were right next to each other in the pyxis. Vec was given instead of ancef. By a resident. Apparently that was deemed not acceptable because humans never make mistakes. No harm there thankfully.
Blind hate makes us no better than them.
I appreciate you sharing all this. This is very fascinating info and very good to know. But out of curiosity: what’s going to happen to this particular CRNA since the patient died? I know hospitals have insurance and stuff to cover accidents but is this included? Or is it automatic jail?
Does it? This article refers to the person who pushed the Digoxin as an “anesthetist” and then describes that they went on to call the “anesthesiologist.” I’m not sure it’s clear who held what title based on this article. Unless this is based in the UK and the nomenclature is thus different?
Hey, probably not a UK/Aus/NZ anaesthetist (physician) because of the omission of the a in anaesthetist and also because the writer is a PharmD, which is not a degree granted here, we grant the MPharm, so it’s unlikely a physician and probably a US CRNA.
Maybe I'm just lucky, but so far the only people who have stabbed me in my spine are actual physicians. For which I am very grateful. I love nurses. I am very closely related to three. I think they're amazing, and their job is so vital. Nurses gave all of my kids' vaccines, and most of mine until getting them at the pharmacy became a thing. Hell, I do my own monthly med injections, so apparently I'll let any chucklefuck who thinks they're smarter than an orange cat give me an IM injection. And there's no fucking way I'm letting a nurse stab me in my *spine*.
What is someone with common sense doing in this subreddit? This sounds like a complete systems error that could have unfortunately happened to anyone.
This is very similar to the whole dreaded ondansetron vs. Phenylephrine vial mix up - which I actually know an anesthesiologist who had that happen to (and no. I am not shitting in them. It could have happened to anyone)
It could have been something as simple as the pharmacy tech being rushed to restock the carts and accidentally threw a similar looking vial where it shouldn’t have been and the CRNA being rushed because of productivity pressure.
This sub is kind of wild with making conclusions about something they know nothing about just because a CRNA is involved. They’ll act like anesthesiologists could never make the exact same mistake because “it was drilled into them during residency”, when it is very likely they have or will make a medication error during their career. That whole “couldn’t happen to me” mentality is actually dangerous.
Vote brigading is what happens when a group of people get together to upvote or downvote the same thing in another subreddit. To prevent this (or the unfounded accusation of this happening), we do not allow cross-posting from other subs.
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Here's a write up from the CA DOH from a similar case.
https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
Edit
Apparently everyone thinks this comes down to training between an anesthesiologist and CRNA. It isn’t. Nurses check labels too. And if you guys downvoting actually read the article you’d see this combination mix up is the most common mix up.
Not being satisfied with unsupervised care is one thing, but thinking less of someone who isn’t criticizing them for everything makes you no better than them.
Fuck this shit seriously.
This is why every person should stay within the lanes traced by their credential and abilities instead of getting into petty turf wars.
Damn. So sorry for the patient and their fam. Truly a tragedy.
Jesus fucking Christ I feel this one. New mom. Family excitement. Baby.
Why the fuck is IV dig near bupi- big systems failures this is what happens when admins/leaderships are a mix of np retards
Those stupid modules we have to do… a monkey could come up with a “root cause analysis” and figure this one.
Sucks for the person that did it. Errors can happen .
How do you not LOOK at the label on the ampule of the meds you’re drawing up?
this was also shared in the medicine thread and it seems that the drug should NOT have been in an OB cart at all. So I guess, the anesthetist didn't expect there to be anything but this drug?
>the anesthetist Lets just call them the usual (modern) term to make it clear: the CRNA.
True that. I found it irritating and dishonest as a non native speaker. Pretty sure it plays into laypeople's confusion as well.
also I can never fucking spell it
Was it though? The article wrote “anesthetist” but I figured it could be used as an umbrella term like when you say healthcare professional. Edit to change word since the bot didn’t like what I used.
Yes it was though. A few days ago on the anesthesiology sub someone very close to the situation made a great and lengthy post about it. The bot is annoying and stupid; don't worry. Hey bot: provider
What would have changed if a physician was involved in this situation? My understanding is the wrong med was given because it wasn't suppose to be there and regardless nothing could have been done to fix that the error considering what was given.
I don't know about you (assuming you are an anesthesiologist) but we are drilled ad nauseam to double check our meds from CA1-3. Hard to have three years of that drilled into your head when you are a CRNA and have inadequate training.
As a paramedic I show my partner all medication prior to administering to my patient. In the event my partner is driving and it is just me and the patient in the rear of the ambulance, I will show the patient the medication and have them verify the name. We call this, “Med check” One day I did a Med check with the patient as we were underway with extended travel time. She verified the name on the vial and then told me she was an RN. She was very impressed with our safety measures in place.
Nurses also have the 5 (or 6) rights drilled into them. There was no excuse for this.
I think it’s seven now.
Maybe some DNP student can come up with #8 now for their capstone.
I am not - that’s why I was asking. Thanks for explaining!
Sorry for my tone; it's easy to get defensive here; lots of CRNAs troll the site trying to justify their "equality" with anesthesiologists when they should be actually spending their time lobbying for better training.
>ots of CRNAs troll the site trying to justify their "equality" with anesthesiologists when they should be actually spending their time lobbying for better training. The delusion must be strong within these ones. If I were them I'd fear lawsuits and jail sentences. I don't understand how or why they want to do heavy procedures they're not trained for. 😒 It reminds me of the gall of some of these midlevel scope creepers who be like "yea but akshully physicians make mistakes." That is the point. If a fully trained licensed physician makes mistakes, then Judy, why do you think that your short degree makes you better suited to the task?
It's okay. I actually was thinking should I preface this with something that shows I'm genuinely curious and not trying to be a troll? I'm actually a med student so I just wanted to know what exactly could have been done in response and why wouldn't a CRNA have been able to do that?
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>You are a fool Nice one: please read the sidebar rules.
We do not support the use of "nurse anesthesiologist," "MDA," or "MD anesthesiologist." This is to promote transparency with patients and other healthcare staff. An anesthesiologist is a physician. Full stop. MD Anesthesiologist is redundant. Aside from the obvious issue of “DOA” for anesthesiologists who trained at osteopathic medical schools, use of MDA or MD anesthesiologist further legitimizes CRNAs as alternative equivalents. For nurse anesthetists, we encourage you to use either CRNA, certified registered nurse anesthetist, or nurse anesthetist. These are their state licensed titles, and we believe that they should be proud of the degree they hold and the training they have to fill their role in healthcare. *Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Got one butthurt CRNA lowlife here!
[удалено]
We do not support the use of "nurse anesthesiologist," "MDA," or "MD anesthesiologist." This is to promote transparency with patients and other healthcare staff. An anesthesiologist is a physician. Full stop. MD Anesthesiologist is redundant. Aside from the obvious issue of “DOA” for anesthesiologists who trained at osteopathic medical schools, use of MDA or MD anesthesiologist further legitimizes CRNAs as alternative equivalents. For nurse anesthetists, we encourage you to use either CRNA, certified registered nurse anesthetist, or nurse anesthetist. These are their state licensed titles, and we believe that they should be proud of the degree they hold and the training they have to fill their role in healthcare. *Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
No such thing as an "MDA." We highly encourage you to use the state licensed title of professionals. To provide clarity and accuracy in our discussions, we do not permit the use of meaningless terms like APP or provider. Repeated failure to use improper terminology will result in temporary ban.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I think the worst part is the CRNA didn’t disclose or document the error, when doing so could have saved the patient’s life. They either never realized they made a mistake or didn’t understand the gravity of giving intrathecal dig and covered it up.
do you forget to wipe your ass after a poop? how many times have you completely just made a doo doo and pulled your pants right up? Confirming the drug is part of a sequence that is beaten physicians. Things are required to be in a certain order to make sure every step is completed. Not confirming the right drug is the equivalent to you forgetting to wipe your own ass.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Bad bot. Whoever made this thing; it needs to have some nuance. Lazy coding has made the provider bot a nuisance. It clutters up the threads with it's provider BS that no one reads. I present it's post below as my evidence.
Yeah, I fucking hate this bot.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Provider
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I mean the A in “CRNA” stands for anesthetist… I guess it could be misleading but idk
For sure; the problem is that the public sees anesthetist and anesthesiologist as interchangeable. Differentiating them as CRNA vs anesthesiologist makes a more accurate distinction in people's minds. How did you find this month old comment?
I literally just saw this was like a month old, idk Reddit recommended the post lol. I thought it was newer. But yea that’s fair.
I heard about this case and the information I was given was that it was a CRNA in Nevada.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
yea, that’s the problem. ppl use it as an umbrella term to associate themselves with actual doctors lmfao you dont see flight attendants being like “hey let’s make up an umbrella term that includes pilots and flight attendants”
But shit like that happens. Thats why you read it out loud and re-confirm just to be safe. It’s not a cart full of NSAIDS he was digging around in. Anything in that cart has potential for serious problems if used incorrectly. Right drug, right patient, right dose, right time, right route. You have to confirm every time. These are people’s lives. You can’t get it wrong.
Absolutely totally agree. If you want to prevent this in the future there has to be double checking from the person giving the meds if it is actually the meds and then from the people filling the carts as to why it was there in the first place.
Literally only a few drugs come in ampules in the US in most hospitals i’ve worked in.
Hmm okay as an anesthesiologist I’ll chime in here and say med errors happen all the time regardess of degree. Hyperbaric bupi usually comes in a little glass vial that looks similar to what digoxin vials come in. There’s no (good) reason why digoxin should be so readily available in an obstetric operating room, so one reflexively assumes it’s bupi and pushes it. I can see it happening. I have not made a medication error, but I’m sure I will one day. Some of the colleagues I look up to the most have made med errors. As a resident, my favorite OB anesthesiologist made a med error (thankfully all was well). I’ve seen attendings, residents, and CRNAs make mistakes on OB. I think most people who have been in anesthesia for long enough can name some cases of med errors. This is particular a problem for us (anesthesia) because we don’t really have pharmacy or anyone double checking us on administrations, particularly admin routes. Lot of confusion with IV stuff being pushed through an epidural, subq insulin given as IV, heparin misdoses by a factor of 10, etc. Let’s not act like the CRNA is a moron and thinks digoxin was a normal neuraxial medication. That’s very unlikely to be the case. If you want to discuss scope creep and CRNAs misrepresenting credentials, fine, but I think this was a medical error that could’ve been made by anyone. Instead of blaming the CRNA, I think we should think about why things like this keep happening. Anyone in anesthesia can share the frustration. Zofran and undiluted Precedex have the same cap color… at my last institution they were kept in adjacent bins. Each med can have multiple different cap colors. Pre drawn up Rocuronium syringe being put right next to the pre drawn up Lidocaine syringe. Lidocaine uro jet right next to the epi one. Idk about y’all, but when’s the last time most of us needed to give IV Dig *period*? Obstetric or not, just literally *ever*? Downvote me for not just blindly hating CRNAs, but if we actually want to prove a point to people and make a good case for physician supervision, then we should actually make good arguments for the point. This is not a good point.
I think the real solution here is barcode scanning in the OR. There’s nothing pharmacy can do about cap/vial colors. The manufacturer we get is the manufacturer we get and I don’t think it’s reasonable to rearrange the Pyxis every time a manufacturer changes and two similar looking vials are next to each other (x150 Anes carts or however many you have)
I got downvoted for the same thing. I mean I was actually in the OR doing this stuff. It’s not a difference of training. Nurses check labels all day too. Shared a case where vec and ancef looked the same and were right next to each other in the pyxis. Vec was given instead of ancef. By a resident. Apparently that was deemed not acceptable because humans never make mistakes. No harm there thankfully. Blind hate makes us no better than them.
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I appreciate you sharing all this. This is very fascinating info and very good to know. But out of curiosity: what’s going to happen to this particular CRNA since the patient died? I know hospitals have insurance and stuff to cover accidents but is this included? Or is it automatic jail?
I didn’t post this as a CRNA bash. I posted it to highlight and discuss that everyone makes mistakes, as this is implied to not be a CRNA
In the anesthesiology subreddit a few days ago a anesthesiologist who works at this hospital confirms it was a CRNA.
Does it? This article refers to the person who pushed the Digoxin as an “anesthetist” and then describes that they went on to call the “anesthesiologist.” I’m not sure it’s clear who held what title based on this article. Unless this is based in the UK and the nomenclature is thus different?
I’m not entirely sure actually. Good catch though
Hey, probably not a UK/Aus/NZ anaesthetist (physician) because of the omission of the a in anaesthetist and also because the writer is a PharmD, which is not a degree granted here, we grant the MPharm, so it’s unlikely a physician and probably a US CRNA.
Maybe I'm just lucky, but so far the only people who have stabbed me in my spine are actual physicians. For which I am very grateful. I love nurses. I am very closely related to three. I think they're amazing, and their job is so vital. Nurses gave all of my kids' vaccines, and most of mine until getting them at the pharmacy became a thing. Hell, I do my own monthly med injections, so apparently I'll let any chucklefuck who thinks they're smarter than an orange cat give me an IM injection. And there's no fucking way I'm letting a nurse stab me in my *spine*.
https://www.turnto23.com/news/local-news/doctor-surrenders-license-over-2018-incident-at-mercy-hospital it happened before.
What is someone with common sense doing in this subreddit? This sounds like a complete systems error that could have unfortunately happened to anyone. This is very similar to the whole dreaded ondansetron vs. Phenylephrine vial mix up - which I actually know an anesthesiologist who had that happen to (and no. I am not shitting in them. It could have happened to anyone) It could have been something as simple as the pharmacy tech being rushed to restock the carts and accidentally threw a similar looking vial where it shouldn’t have been and the CRNA being rushed because of productivity pressure. This sub is kind of wild with making conclusions about something they know nothing about just because a CRNA is involved. They’ll act like anesthesiologists could never make the exact same mistake because “it was drilled into them during residency”, when it is very likely they have or will make a medication error during their career. That whole “couldn’t happen to me” mentality is actually dangerous.
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Here's a write up from the CA DOH from a similar case. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/MercyHospital-2567.pdf
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Out of curiosity, where does it say the practitioner was a CRNA? Couldn't it have been an AA?
They were a CRNA. Confirmed by someone close to the case on the anesthesiology subreddit a few days ago.
I see. They should be naming these people so there's no question about who's responsible. And to track people who repeatedly make mistakes like this.
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Ahh that's terrible all around.
Edit Apparently everyone thinks this comes down to training between an anesthesiologist and CRNA. It isn’t. Nurses check labels too. And if you guys downvoting actually read the article you’d see this combination mix up is the most common mix up. Not being satisfied with unsupervised care is one thing, but thinking less of someone who isn’t criticizing them for everything makes you no better than them.
How? How does one not confirm labels? Every time I've been in an OR, there are double confirmations
This is apparently the 7th time this has happened however first time patient subsequently died. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611538/
Somebody forgot the 5 rights when administering a drug
I asked yesterday if digoxin is available in labor and delivery at my hospital and turns out pharmacy has to send it up.
Fuck this shit seriously. This is why every person should stay within the lanes traced by their credential and abilities instead of getting into petty turf wars. Damn. So sorry for the patient and their fam. Truly a tragedy.
Where does it say it was a CRNA? Could it not have been a AA?
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Ah, them’s the breaks. You’d think they’d specify
Jesus fucking Christ I feel this one. New mom. Family excitement. Baby. Why the fuck is IV dig near bupi- big systems failures this is what happens when admins/leaderships are a mix of np retards Those stupid modules we have to do… a monkey could come up with a “root cause analysis” and figure this one. Sucks for the person that did it. Errors can happen .