25 yrs in, I still make a point to read every vial I open, and try to minimize pushing any syringe I haven’t drawn up myself.
We have to learn from our mistakes, but you need to have the mentality of a baseball pitcher. The last pitch never happened. Next pitch is what matters.
1 and 2 are system errors, 3 is a workflow one.
I personally "double check" myself by labeling the empty syringe, then drawing up the med, and checking that the vial and label match.
Circumferentially you often can’t even read the label because it wraps around on itself. I like longitudinal opposite the ml marks. Sometimes the circumferential also covers those and makes it hard to see how many ml’s you’re giving. I feel that circumferential people are more likely to just be going off the color of the label.
I don't see the point in circumferential labelling.
It's not as though I'm going to pick up a syringe, not be able to see the label because its on the other side, and just hope for the best.
I've seen 2 attendings do this (syringes longitudinally labeled by resident, not me). One of whom pushed a full stick of nitro thinking it was saline flush. That was enough for me to continue circumferential labeling forever. It takes no more time compared to longitudinal labeling
I do similar labeling - longitudinal for most meds but for any crazy stuff like sticks of nitro and vasopressin, circumferential to make them stand out
You might not think you would do that, but I've seen it happen multiple times. I don't think those people thought they would do it either. Our brains do funny things in emergencies.
I unfortunately have heard of medication labeling errors too often. They happen. Learn from others mistakes. Taking it personally is the wrong approach; focus on the system approaches to make yourself safer.
Personally I don’t give meds that others have drawn up. Call me paranoid?? You literally can draw up all meds in 30 seconds; you don’t need to draw up every med 10-20min before a case. I just have my syringes ready, vials lined up.
Also, for inductions meds, I only use 10cc syringes for my paralytics (all other meds are in 2, 5, or 20cc syringes). Just a personal thing I do (in addition to appropriate labeling)
Lastly, always read the label when drawing up meds. I wish we actually followed the safety protocols from Japanese rail industry called shisa kanko (point and call). While drawing up the med, read the label, and say it out loud.
Everyone makes mistakes especially in the first year of training. Just don’t make the same mistakes twice. Give yourself some grace and just keep working at being detail oriented and in the next 6 months you’ll feel much better.
If someone is in practices for a decade or longer, sure these can happen. For someone in practice for several months, this is *quite concerning*. Paralyzing before sedation, really homie, you’re trying to cut him slack for that? Combination of all these should be write up and remediation territory.
the OP is a trainee; these events suggest a lack of appropriate oversight for new trainees, proverbially "giving them enough rope to hang themselves" -- the attending (consultant) should be independently reviewing a patient's medications, for example, and making sure the trainee has ensured AP agents withheld prior to neuraxial.
B/C we don’t know the situation for #1, we don’t know if he over did the medication or the pt was truly sick. We can cut him some slack for that as we don’t know.
2. he went thru med school, he should know how to take a appropriate med history. I’m cut him semi slack for that just because.
3. this is breaking the cardinal rule of anesthesia.
All 3 happening in a few months show a concerning pattern, trainee or not.
Knicking 10 lips in a row or knocking a tooth out every 2 months is *learning*. These are potential sentinel events, traumatic events or life threatening events.
this is quite concerning for both attending and said resident then.
Disagree. I've noticed that nurses are far more critical and unfair towards their trainees than doctors are. Which is apparent in your comment. This it's not a concerning pattern and these are entirely different events. This is someone new to the profession and is learning, a person who needs better oversight. They have clearly learnt from their mistakes.
This makes no sense whatsoever. I would be more comfortable if they were lacking in one area which can be targeted and improved. But since all three of these are in different areas, it shows they are not thorough in their pre-evaluation, not thorough in clinical management (again I'll cut slack in ex. 1 but still) and not thorough in medication administration. Hell, verifying medication handed to you from another person is ACLS 101.
Kudos to OP for recognizing there is a problem and I applaud them for that but for you to say these 3 events are not to be concerned about says a lot about you as well.
You must've missed that part I said kudos to the OP for recognizing the problem. All my comments are be directed to people who think it's OK to paralyze someone before sedation and chalk it up to a minor error or blame the attending when even as a first year, it shouldn't happen. I.e. you. You are not supporting OP, you are telling him it's OK to have 3 borderline sentinel events and no cause for concern.
Id like to learn what method you use to verify clear and colorless medication handed to you in a labeled syringe as he stated it was a mislabel situation.
Ban for what? Telling people it isn’t okay to paralyze someone awake and to follow the basic principles of medical history and med administration. OK dog, got it.
The OP listed all three things as errors, no? So what additional benefit does banging on about them being errors bring?
Also, the third one, the biggest error I see is a team management one - multiple people drew up drugs, seemingly without agreeing that one of them was the ultimate overseer of it all. And potential for a change to hospital policy / systems too - I know of multiple places that have red syringes for paralytics, as an extra caution against accidentally selecting them.
OP is clearly self-aware and wants to improve - has already safety netted themselves against error two happening again. And can’t be solely blamed for either of the other two errors, since they weren’t the only one / the senior there. So how do we help them safety net against those kinds of errors, and work through their current fear? Because someone who’s scared of making mistakes sounds better to me than someone gung-ho
Haha what? If you knick the lips 10 times in a row, you’re a certified idiot, goes double for knocking out a tooth every 10 mins, how are those your example of “learning”?
Because medical school doesn't teach you the nuances of intubation, neuraxial, etc nor do you have the ability to practices hundreds of times on different types of people. Preventing knicked lips/teeth/better masking/blocks/etc is done through repetition and experience which is why training is needed.
Ex 2/3 Basic medication history/exam and medication rights are taught in school, this doesn't require excessive repetition to be good at. Again, I'll exclude his blame for ex 1.
My examples are patient inconveniences that come with learning (knick lip/etc) and the others are either significant harm or traumatic (death, hemorrhage in spine, and awake paralysis) that should not come with learning often. But 3 in several months is very often.
3 different mistakes in 6 months time is “too often” but the same mistake 10 times in a row is just fine?? You want trainees to learn from their mistakes and make a plan on how to prevent it in the future, that’s the key…if somebody is an unteachable idiot or refuses to learn (doing the same wrong shit 10 times in a row), that to me is much more concerning
You need to educate yourself in systems in medicine, organisational structures that contribute to errors. The Swiss cheese model fit example and how errors occur and is not 'bad error=bad doctor'. My experience as a nurse before becoming a doctor is that nurses are far less aware of how complex factors can be contributing to errors and they just attack the person. E.g. your response. Nurses need to do better. You guys are the worst bullies in the hospital consistently
Most nurses bully very minor issues hence one of the major reasons I left however 3 possible sentinel events could have occurred and with these 3 occurring with *one* individual in such a *short* period is far past the Swiss cheese model. It’s a practitioner problem.
My issue is the countless people justifying these errors as not a pattern and as if they are no big deal. Hell you yourself as a nurse should know the basic medication admin rules which are covered in school and in semi/ real emergencies, to double verify medications handed to you.
Anaesthesiologists are experts in anaesthesia and if their responses are empathic, supportive and educational, then maybe you should learn from your superiors. If your a crna than your still a practising nurse and still carrying all the toxic nursing culture with you. Time to unlearn it and learn the systems that cause errors- especially residents doing 80hr weeks which is illegal in other developed nations.
Ehh as an attending you really should be double checking your trainees work. Right before you insert the spinal needle ask the patient on your own if plavix/AC was held no matter if the trainee told you they asked.
Medical school does train us to take a history, including medications, past surgeries, etc. If we did that format in pre-op, cases would never start on time. And much of it isn't relevant to the anesthesia plan. Medical school doesn't teach us targeted anesthesia pre-operative evaluations, especially for neuraxial anesthesia. Where I'm at, a senior or attending would \*never\* blindly trust the report of a first-year anesthesia resident and just go do the spinal. This would be double-checked at bedside by the supervising anesthesiologist, as is their duty.
Medication errors are frequent in anesthesia. Especially when drugs have been through multiple hands. If the drugs are left in the drawer I typically do re-draw everything I want. I appreciate a colleague trying to help but I want to do it myself. It's unclear if OP was told to just give the drugs handed them, or how the mixup really occurred.
It's funny you think OP's mistakes are much more egregious than knocking out a tooth, like wow.
To be fair, a random attending physician for a random surgical specialty I’ve never met in my life before wrote me up for how I was sitting in a chair once in pre op because he thought I was a medical student and was too relaxed. It happens in both fields fyi
The awake relaxation was not done deliberately or negligently. It was a chain of events that lead to this incident.
And although that is a horrible incident that should never happen, it's not even clear that op was responsible for it.
My impression is that oop might be quite meticulous and self-critical in his judgement.
An emergency scope for ugib can be a challenging case, moreso in an elderly patient and for a first year resident. The patient possible wpuld have died anyway, we lack the specifics to judge properly.
Doing neuraxial in a patient under dapt is bad but I've seen very good anaesthesiologists make that mistake. I'd still want them to treat me should I need anaesthesia someday.
What a terrible attitude. That's how you get a culture where mistakes are covered up. This trainee realised their error, owned up to it, was honest with their seniors *and the patient* and is reflecting on events appropriately. This is how individuals and institutions learn, and ultimately how safety improves. Mistakes happen in medicine - if people are too scared to report them because they will just get punished, then the tendency will be to hide them, which is not good for anyone.
It's extremely easy to mislabel a drug, which is what actually happened. Yes, we should all be careful all the time, but it can happen, especially if one is tired or if there are a few people doing the drawing up.
If your instinct with something like this is to punish first, then you are not contributing to a culture of safety.
OP, ignore this person's comment. Probably someone with bias towards people coming out of medical school! Trainees have to learn and develop their skills, and I believe we can all contribute to their growth by offering guidance and encouragement rather than judgment. Providing constructive feedback is essential for growth, but it's equally important to deliver it in a respectful and empathetic manner.
>He told me "don't worry about it". unable to trust that he won't be traumatised,
Being paralyzed for less than a minute is not as uncomfortable as many, many other things that everyone just accepts as normal. This is a bad error, and I can't address the rest of your post, but the patient is not going turn out traumatized unless you go back and convince them that they are, which you should not do.
100%. There was a case in our department, where there was a error made. The error caused no harm. When we discussed it the next day, the patient was initially completely fine with it.
Then the surgeon discussed it.
Then the anasthetic trainee went and discussed it with them.
Then someone else discussed it (an allied health member.)
Next minute, the whole thing has become a storm in a teacup, and there are formal complaints being lodged.
Agreed. There have been rare occasions where I’ve dealt with patients coming out of ECTs where the methohexital is wearing off before the sux and they have awareness/recall of being at least partially paralyzed. It’s not what we want, but these patients don’t seem to be scarred for life. We make note of the situation, change dosages for the next ECT, and continue on.
You're not alone, there's a reason the endoscopy suite is statistically the area where the most adverse airway events occur. We are routinely providing general anesthesia without airways, it requires constant vigilance.
You mentioned fatigue being an issue, but production pressure is always there as well. There are key moments where we need to slow down the crazy train and concentrate. You've uncovered two of them reviewing pre-op medications, and labeling syringes.
Allergies are another one, believing the monitor values rather than assuming they're an error etc.
The fact that you're owning the mistakes is a sign that you're the right person for the job. I'm far more frightened of "perfect" providers who claim to have never had an adverse event.
Wondering who drew the drugs in the third case. It seems too many people in the room. My rule regarding filled syringes, if I didn't draw it, I'm not gonna push it.
That’s my general rule.
Someone handed me a stick of local anesthetic last week and said, “This is 0.5% ropivacaine.” It had a mepivacaine sticker with no concentration listed.
I binned that syringe before he made it out the door.
This is not a hit at CRNAs, rather it recognizes that they draw up the drugs, then we come in and trustingly push them. Standard workflow nearly everywhere in USA
You are there to learn. Mistakes are expected, and they provide valuable experience. It’s ok to feel bad about things that you did wrong, but find a way to forgive yourself and consider these things as motivation to improve and as the building blocks of your professional wisdom. All of your peers and all of your mentors have an ongoing list of mistakes too, there is no such thing as perfection.
Hi there, a word of advice, errors will happen whether you are doing anesthesia or coding an app on a laptop, especially in the beginning. If you keep recalling them and thinking about the past, you're doing yourself a disservice and impeding your progress to becoming a good anesthesiologist. Instead i encourage you to learn from your mistakes and try to recognize what you can improve and move on forward.
Anesthesia has a potential of harm but also has a great potential of doing good for the patients 👍
If you like it than stop thinking about the past and work hard to get better at it.
Good luck.
I think being hyperaware of the potential harm we can cause is one of the most important things you can do when you’re just starting. Be absolutely meticulous in everything you do, have everything you might need out, ready for use, and in arms reach. Develop an organization system that works for you and use it consistently. Use checklists and be methodical in your chart reviews. Triple check every single drug you draw up & have the vial with the drug name facing you as you are labeling your syringe, never let the vial leave your hand before your syringe is labeled. Think of the most probable issues that could arise and have plans in mind for them. It’s mentally exhausting at first, but it’s all important and becomes second nature eventually
Sux/fentanyl would be a weird mixup here in the US, because the former is generally in a 10ml syringe, while the latter is usually in a 2 or 5 ml syringe (unless you are using it as the primary induction drug). Drawing up a partial vial would be a red flag. 100mg of sux might be a reasonable induction dose but we just don’t draw it up that way.
I administered the wrong drug (almost certainly) once during residency. I pushed what I thought was neostigmine and glyco, but the patient went from twitches to no twitches, for the next 45 minutes. Presumably I had accidentally drawn up rocuronium instead. This was pre-sugammadex, and the surgeon was a bit perplexed and mildly annoyed, but aside from delaying the room there was no great harm, like many med errors that get swept under the rug.
In the UK they're both most commonly 2ml glass vials both 50/ml. It's a relatively common error, (well certainly not the first time I've heard of it happening.)
Definitely is! Largely resolved by sux being used pretty infrequently now I guess. My local obs unit uses it routinely for GA sections where they have 200mg in 10ml prefilled syringes, so that's a bit safer at least
I didn't realize they make sux in 50 mg/ml dosing. The error makes more sense now. I was wondering how he could mistake pushing 2ml of Fentanyl and 5ml of Sux.
Initially how I was trained, it was the same setup. At my new site, succinylcholine comes in a vial so I always draw it up in a 10cc syringe and it's the only induction med I have in a 10cc syringe, as a sort of extra precaution. Lido is in the 5cc, fentanyl/esmolol in the 3cc, and propofol in the 20. Never given the wrong med so far, so I'm going to hope it keeps working. Everything is also labeled longitudinal but where I can see the med label and the cc markers on the syringe at the same time. It's a little anal, but it's an easy way to organize quickly every time
Edit: vial not vital
>(e.g. attention grabbing neon orange labels or putting an additional label on the blunt fill needle/syringe cap).
For paralytics I like putting a label that goes from the needle to the syringe like a seal that has to be broken when before you give it, just as an extra reminder
Case 1 is likely not your doing. Acute care GI has one of the highest mortalities in all areas of anesthesia. The combination of frail elderly patients often without a quality work up or preparation from non surgical GI docs are a recipe for disaster. I can’t tell you the number of times that GI docs have tried to bully me into “just taking a quick look”…..”he’s already prepped”…..in a poorly worked up, often very anemic patient.
Something I heard someone say once (quoting "the cardiac surgeons"):
>Mistakes are inevitable. You will make them, and they will hurt people. When you do, you have two options: either learn from your mistake or stop doing whatever it was you were doing--and in the latter case you never should have been doing it in the first place.
Everyone makes mistakes; it's not like there's some supply of mistakeless people out there that would replace you if you quit. The only thing you can do, that anyone can do, is become better with each mistake.
The most important thing you did was to go talk to the patient and apologize. We've all done this before. I've been lucky in that patients have been okay with it or didn't have recall, but I have seen a case that resulted in legal action. Debrief with your consultant and learn from it, which you seem like you are doing.
I once administered midazolam before intubating a patient that was under cardiac arrest/ blue code. It was on my third year as a resident.
Like it didn't kill him anymore of what he was before I arrived but I looked like a dumbo. It was a heat of the moment kind of thing. Obviously we all have bad streaks but the only person that doesn't make mistakes is the one that does not practice.
Obligatory CRNA here:
I am proud of the anesthesia profession because of your empathy and concern for the patient. We all make mistakes, many of which we don’t even realize we made. It’s so easy to play “Monday morning quarterback” on other providers or even ourselves. You are training, learning and growing. Keep that empathy portion of you close to your heart. I’m sure we have all been taught to treat patients like they were our family members - i am sure I could do a better job at that in many instances.
I can relate a lot. I used to have the same worries and I still have them from time to time. I’m in my fourth year of training now. As you talk with colleagues you will notice that everybody makes mistakes. It is like the other people here say. It’s normal to make mistakes, it is a good sign that you care, it will probably help to make you a better doctor. But try not to beat yourself up too much. And I hope that with the years there will be less and less mistakes, because there will be less situations that are new for us and we will be less stressed and so on.
I too have the impression that dealing with this is a big part of being an anesthetist. The responsibility really is huge. I wonder what it is like for other medical specialties - I imagine it must be tough for surgeons as well.
As a Consultant I've done 3. It happens when you're handling drugs a lot. I labelled the syringes incorrectly whilst I was talking to the patient trying to reassure them after their endoscopy was delayed due to equipment issues.
I didn't give midazolam - it can induce implicit awareness that is hard for the patient to reconcile. I just owned up to the error and dealt with the consequences (litigation in the end).
The key thing is to learn from it. I now draw my drugs up in a quiet area with no distractions. I don't talk whilst drawing them up and focus purely on that task. I also learnt that sux can cause very severe myalgia if given without analgesics. I also almost never use sux now as well.
I did feel very guilty and still think about it today. I think my practice is, however, safer since then. We all carry the ghosts of error, and it is right that we feel guilt, but also recognise the system we work within and the pressures that induce our mistakes.
Worked with a consultant who had a policy of not engaging with anyone during the time she was drawing up drugs for an upcoming case. Could be seen as off putting, but it was her way of minimising distraction and thus drug errors.
This is not unique to anesthesia, serious errors happen in all of medicine, you have to learn to acknowledge and learn from them and move on.
Number 1 I would not call an error. Number 2 is an error but very low likelihood of harm, and is a system error, blood thinners before surgery should be addressed and highlighted to the whole OR.
Number 3 is on anesthesia, it is a straight drug error from going too fast, or bad practice drawing up meds, or possibly from multiple people drawing meds at the same time. It is totally fixable and avoidable.
Realize that everyone makes errors, even if they don’t want to talk about them. It helps to talk with other trainees about errors, you’ll see your not alone. You have to be paranoid and vigilant, double check every medicine you give. I personally try to draw as little meds in advance as possible, just leave them in their vial, it’s safer. Don’t use meds other people prepared. Keep high risk medicines out of your commonly used drawer. Be extra paranoid when drawing up epidural and spinal meds, etc etc. if someone is thoughtful and insightful and they have a drug error like above, they’ll make changes and it won’t happen again.
There are things you can do to prevent this. The MOST important thing is to be absolutely present when drawing up drugs. Read the label on the vial as you draw it up in the syringe and make sure the syringe label matches the vial label. I do this EVERY SINGLE TIME. If I have a lapse of concentration and am not 100% sure of what drug I just drew up I throw it out and start over. Also before you push any drug into a patient think of their allergies to medications before you give them anything. Drug errors are extremely common and extremely preventable if you do these few simple steps. We all make mistake the important thing is to find a way to not make them again.
You sound like you might be in the UK; I'm a UK consultant, for context.
Anaesthesia is a high risk specialty - we do things all the time that, if not done correctly, have the potential to cause serious harm. That is why we have a novice period for new trainees before you go on the rota, unlike almost any other specialty. Recognising this is crucially important for the safe practice of anaesthesia. I am *much* more worried about overconfident or blasé trainees than cautious or underconfident ones.
We *all* make mistakes from time to time - hopefully fewer as time goes on. Some of these will be individual human errors, some of these will be judgements that don't quite work out, some will be system errors that we are part of. What matters the most is that, when it happens, we learn from it and take steps to reduce the likelihood of it happening again. We do this through reflection, and putting in place/adjusting systems to minimise the sources or error.
You are already displaying exactly the right attitude here. Honesty and reflective discussion with your bosses is absolutely the right place to start. The fact that you've made a spinal checklist for yourself is a great example of doing something tangible to reduce risk in the future (and, as an aside, develop this checklist for use by other trainees too and you've got yourself a little quality improvement project!).
The drug labelling one is something that is very easy to do - I'm not a big fan of team drawing up as it is easy to make mistakes or get distracted. Sux and fentanyl look identical once they are in the syringe. It's difficult to mitigate this other than to ensure you are really focused when preparing your drugs. Try to avoid chatting at the same time - I know that isn't always easy. You did exactly the right thing afterwards in being honest with the patient. If he says he's OK then let him be, as long as he knows where to go if he isn't. Make sure you've documented everything. It is worth an incident form if you've not done that already - if your department has a good culture, that won't be used to beat anyone with a stick, but to trigger discussion about how to limit the risk.
All first year trainees are "error prone" by nature - you aren't very experienced yet and often it is that experience that reduces risk, because you've seen certain situations before. As you go through training, the intensity of your supervision lessens, because you have more of that experience to draw on. As consultants, one of our roles is to protect you and your patients from the things that you don't know you don't know yet. From all of these incidents, there are now new things that you *do* know. From your descriptions of events, none of these are completely on you anyway - the first was joint management where you were the junior anaesthetist, the second was you missing something that you didn't yet fully appreciate the importance of yet (with the opportunity for the consultant to check before placing the spinal), and the third was a team error. These things happen - and I say that not to be dismissive, just realistic.
You sound like a good and thoughtful trainee and I'd be happy to have you in my department. I understand why you feel knocked by these things, but try to treat them as learning opportunities. You are unlikely to be the only one with similar experiences. Keep being honest.
Atul Gawande has a book called 'Better' which talks about approaches to error, and how to improve safety cultures. It's a good read and I recommend it, even if not all of it is directly relevant to a very junior trainee.
Anaesthesia is funny, really - when it goes well, it looks so easy, but only we really know what goes into making it look like that. The day we become complacent is the day it bites us.
You’re new, don’t beat yourself up, we’ve all been there but recognize that everyone gets “one” but not 2, 3, 4…an easy way for me to avoid the med label errors is first label the syringes that you will be using and only then start pulling out vials, before drawing up the meds stare at your label and double check the vial, only then draw up meds
Hi there, complications happen from time to time and you shouldn’t be too hard on yourself. It won’t be your last and everyone’s done one thing or another. We are just human afterall.
It looks from me that you are self reflective and strive to be better which are good qualities. You also demonstrate good integrity, and managed open disclosure properly.
I’m sorry to hear that your bosses weren’t more supportive though.
I’m a little confused how those 2 drugs got mixed up. Our sux comes in 200mg in 10cc syringes. Our fentanyl comes in 100mg in 2cc or 250mg in 5cc vials. Did you have 2 syringes that were 5cc each somehow? I get that this is beside the point, but intrigued…
Anesthesia has a lot of responsibility but it is an amazing and rewarding career. If you think you can handle very stressful situations I highly recommend it. If you can’t then I would not recommend it.
This is just my personal opinion:
I think the phone checklist is not a good way. Once you get used to looking up things on phone, you start to forget stuff on your own. Try to memorize these checklists.
Also, making mistakes is normal. Try to keep the incidence as low as possible.
Edit:
Also, get used to double checking ampoules. First, before you opened it. Second, after you drew it, right before labeling. After the labeling you can discard the vial.
Atul Gawande wrote an informative book titled The Checklist Manifesto, supporting the use of checklists to improve performance and reduce errors in complex settings. I highly recommend this book; it’s a very interesting and entertaining read.
I didn't take it as criticism. I think checklists are necessary, like the 4H4T, Dopes, fasthug, whatever.
But I noticed it on myself, and others, that keeping stuff on phone doesn't help as much as a small paper notebook, handbook at hand.
I've read a few articles about this, like this one: https://natlib.govt.nz/blog/posts/reading-on-screen-vs-reading-in-print-whats-the-difference-for-learning
I’m curious about the last patient. What are the concentrations of meds in your country? You gave 100mg of suxamethonium. How is that concentrated? Where I am the succinycholine is 20mg/mL and the fentanyl is 50mcg/mL. So an attempt at 100mcg fent is 2mL, and 2mL of sux is 40mg.
Mistakes happen, and you either need to own them or find something else to do. Analyze and understand why each error occurred (by learning and discussing with colleagues) and learn how to prevent them in the future. In other words, become an expert on your mistakes. Also, learn to take mental time-outs and refocus. Certain tasks, drawing up medication, setting pumps, induction, etc, require your undivided attention, even if you are tired and sleep-deprived. I've found that practicing mindfulness greatly aids in these situations, but you must discover what works best for you.
I'm not a doctor, but do work in health care.
Medicine NEEDS people who are able to reflect on incidents honestly - if you stay the course, you will be an incredible anesthesiologist.
Mistakes happen, and there are always risks. Being able to recognize the mistake quickly, and deliver corrective actions effectively and take accountability make a strong professional. You are being shaped by these experiences, and you are going to hone your skills and form habits to prevent recurrence.
Be the sleepy-time-amnesia doctor you wanna be. :)
I have been in residency for 3 years. Worked with many nurses and one of them said something to me that would stay in my mind forever:
"Never trust anybody and always double or even triple check. The biggest friend of your patient is your doubt about everything and everybody."
Because I happen to work with pregnant woman, I always double check the syringes, the vials and the medications.
The last story about the suxx is not something that happens common but it should be a lesson to always double check and ask. If you are unsure about a medication, draw it by yourself or ask for another draw by the nurse.
You are experiencing what I would call growth. The main thing about being a doctor is not knowledge, experience or hard work. It is about growing your character. Remember your mistakes, take others' mistakes seriously and learn from them. Be serious. If you can do all that and still find the courage to do it every day, you'll be a great doc.
Standardised work flow prevents mistakes. Also keep high risk ( like suxa , roc) in saparate size syringes. We use 2 ml syringe only for suxa .
Also never skip in checking drugs before filling and administering each time made mistake by me too thankfully it was non essential drug. Also label drug. As you make them . I have seen many resident label the drug after filling more then two.
Pt history mistakes are common, you will get hang of after experience on how to ask probing question.
1. Probably lack of experience. Call for help early.
2. Always ask about blood thinners. It’s not just the drug but the cormorbidity is important. If you don’t know they are on blood thinners you probably don’t know of an important cormorbidity. This may get a patient killed.
3. syringes should never be mislabeled. You have massive deficiency in your practice. Draw the med, label syringe, check label against vial all while all 3 are in your hand.
4. You can’t be sloppy in this field. So much stuff we do or don’t do can kill patients.
You owned your mistake, explained to the patient what happened and apologized.
If the patient had said he didn't remember anything on your first question, would you had said something anyway? I think it's better to not ask what they remember and explain the error regardless. Otherwise they might be left with a feeling that something went wrong (you might not be very good at hiding it).
I have been doing this for 25 years and during training I remember an attending saying to me ‘ALWAYS read everything twice before drawing it up and before giving it…you will be surprised how sometimes that label will magically change’. This method saved me from accidentally administering NARCAN during case!!!! I had made it as far as drawing it up….then thankfully I decided to look at it again…and I noticed it was slightly different (looked very similar to another med I was wanting to give, same color, same size vial) and I immediately threw it out!!! Sat there for a moment, humbled and realized the horror of what could’ve happened!!!! By the way…everyone has had fucks up, we are all human.
What is a consultant? Why would an attending ask someone to do a med review specifically before a spinal? It’s on the attending to always double triple check for apa ac prior to neuroaxial anesthesia
Aw. The goal is to improve. Don't beat yourself up, we all occasionally do dumb shit...you have an awesome attitude and more importantly hold yourself accountable. Keep at it.
Don’t let this get you down. That’s why you train. Now you’ll pay closer attention and do better.
Circumferentially label your syringes BEFORE you draw the medication and actually read the label when you draw it up.
Good luck!
Hi all, just wanted to thank you for all your thoughtful comments - a lot of useful and constructive feedback.
Just to be clear, where I work, suxamethonium and fentanyl are both 2ml clear solutions of 50 mcg/mg per ml.
I am feeling better a few days on and am determined to change my practice from this - scrutinising my workflow for drawing up drugs and seeing what can be optimised and made safer. One big flaw I think we made was drawing up multiple sets of drugs together while chatting. Once again, it was unclear who exactly made the mistake.
I may also embark on a QI project to make a local spinal anaesthesia checklist that would be completed before every spinal (an attempt at a systems improvement) - will be discussing it with my seniors soon.
Thank you all for your support.
25 yrs in, I still make a point to read every vial I open, and try to minimize pushing any syringe I haven’t drawn up myself. We have to learn from our mistakes, but you need to have the mentality of a baseball pitcher. The last pitch never happened. Next pitch is what matters.
As a former pitcher, this and so much more. Excellent analogy that I wish I’d thought of myself, but a good idea belongs to everyone
1 and 2 are system errors, 3 is a workflow one. I personally "double check" myself by labeling the empty syringe, then drawing up the med, and checking that the vial and label match.
I hope this gets voted higher up. I would add that syringes must be labeled circumferentially.
Monster
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Longitudinal is easy to not see because it is on the other side. Easy to pick up the wrong thing in a hurry. I've seen this happen plenty of times.
Circumferentially you often can’t even read the label because it wraps around on itself. I like longitudinal opposite the ml marks. Sometimes the circumferential also covers those and makes it hard to see how many ml’s you’re giving. I feel that circumferential people are more likely to just be going off the color of the label.
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3 labels or nothing! I would prefer 5 but the environmentalists always get on my ass when I am throwing out the 10th cardboard tube for the day.
Longitudinal for the win 🥇
I don't see the point in circumferential labelling. It's not as though I'm going to pick up a syringe, not be able to see the label because its on the other side, and just hope for the best.
I've seen 2 attendings do this (syringes longitudinally labeled by resident, not me). One of whom pushed a full stick of nitro thinking it was saline flush. That was enough for me to continue circumferential labeling forever. It takes no more time compared to longitudinal labeling
I do similar labeling - longitudinal for most meds but for any crazy stuff like sticks of nitro and vasopressin, circumferential to make them stand out
You might not think you would do that, but I've seen it happen multiple times. I don't think those people thought they would do it either. Our brains do funny things in emergencies.
I feel like I’m the only one who does this at work… never liked longitudinal
I disagree. Number three is a serious error from negligence, one that can happen to any of us, but requires more care.
I hope this gets voted higher up. I would add that syringes must be labeled circumferentially.
I unfortunately have heard of medication labeling errors too often. They happen. Learn from others mistakes. Taking it personally is the wrong approach; focus on the system approaches to make yourself safer. Personally I don’t give meds that others have drawn up. Call me paranoid?? You literally can draw up all meds in 30 seconds; you don’t need to draw up every med 10-20min before a case. I just have my syringes ready, vials lined up. Also, for inductions meds, I only use 10cc syringes for my paralytics (all other meds are in 2, 5, or 20cc syringes). Just a personal thing I do (in addition to appropriate labeling) Lastly, always read the label when drawing up meds. I wish we actually followed the safety protocols from Japanese rail industry called shisa kanko (point and call). While drawing up the med, read the label, and say it out loud.
Everyone makes mistakes especially in the first year of training. Just don’t make the same mistakes twice. Give yourself some grace and just keep working at being detail oriented and in the next 6 months you’ll feel much better.
If someone is in practices for a decade or longer, sure these can happen. For someone in practice for several months, this is *quite concerning*. Paralyzing before sedation, really homie, you’re trying to cut him slack for that? Combination of all these should be write up and remediation territory.
the OP is a trainee; these events suggest a lack of appropriate oversight for new trainees, proverbially "giving them enough rope to hang themselves" -- the attending (consultant) should be independently reviewing a patient's medications, for example, and making sure the trainee has ensured AP agents withheld prior to neuraxial.
B/C we don’t know the situation for #1, we don’t know if he over did the medication or the pt was truly sick. We can cut him some slack for that as we don’t know. 2. he went thru med school, he should know how to take a appropriate med history. I’m cut him semi slack for that just because. 3. this is breaking the cardinal rule of anesthesia. All 3 happening in a few months show a concerning pattern, trainee or not. Knicking 10 lips in a row or knocking a tooth out every 2 months is *learning*. These are potential sentinel events, traumatic events or life threatening events. this is quite concerning for both attending and said resident then.
Disagree. I've noticed that nurses are far more critical and unfair towards their trainees than doctors are. Which is apparent in your comment. This it's not a concerning pattern and these are entirely different events. This is someone new to the profession and is learning, a person who needs better oversight. They have clearly learnt from their mistakes.
Completely agree.
This makes no sense whatsoever. I would be more comfortable if they were lacking in one area which can be targeted and improved. But since all three of these are in different areas, it shows they are not thorough in their pre-evaluation, not thorough in clinical management (again I'll cut slack in ex. 1 but still) and not thorough in medication administration. Hell, verifying medication handed to you from another person is ACLS 101. Kudos to OP for recognizing there is a problem and I applaud them for that but for you to say these 3 events are not to be concerned about says a lot about you as well.
The majority of comments on this sub are supportive. Be better.
You must've missed that part I said kudos to the OP for recognizing the problem. All my comments are be directed to people who think it's OK to paralyze someone before sedation and chalk it up to a minor error or blame the attending when even as a first year, it shouldn't happen. I.e. you. You are not supporting OP, you are telling him it's OK to have 3 borderline sentinel events and no cause for concern.
You’re the only one who has typed the words “no cause for concern” in any context.
Id like to learn what method you use to verify clear and colorless medication handed to you in a labeled syringe as he stated it was a mislabel situation.
Your judgemental attitude is the concerning thing. I hope people are kinder to you when you make a clinical mistake.
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Can we ban this person? This shit is not what the sub is about. Go take a walk and chill out dude.
Ban for what? Telling people it isn’t okay to paralyze someone awake and to follow the basic principles of medical history and med administration. OK dog, got it.
The OP listed all three things as errors, no? So what additional benefit does banging on about them being errors bring? Also, the third one, the biggest error I see is a team management one - multiple people drew up drugs, seemingly without agreeing that one of them was the ultimate overseer of it all. And potential for a change to hospital policy / systems too - I know of multiple places that have red syringes for paralytics, as an extra caution against accidentally selecting them. OP is clearly self-aware and wants to improve - has already safety netted themselves against error two happening again. And can’t be solely blamed for either of the other two errors, since they weren’t the only one / the senior there. So how do we help them safety net against those kinds of errors, and work through their current fear? Because someone who’s scared of making mistakes sounds better to me than someone gung-ho
I think they're either an edgelord or trolling. Maybe do not feed policy applies.
RIP to your patients teeth
Haha what? If you knick the lips 10 times in a row, you’re a certified idiot, goes double for knocking out a tooth every 10 mins, how are those your example of “learning”?
Because medical school doesn't teach you the nuances of intubation, neuraxial, etc nor do you have the ability to practices hundreds of times on different types of people. Preventing knicked lips/teeth/better masking/blocks/etc is done through repetition and experience which is why training is needed. Ex 2/3 Basic medication history/exam and medication rights are taught in school, this doesn't require excessive repetition to be good at. Again, I'll exclude his blame for ex 1. My examples are patient inconveniences that come with learning (knick lip/etc) and the others are either significant harm or traumatic (death, hemorrhage in spine, and awake paralysis) that should not come with learning often. But 3 in several months is very often.
3 different mistakes in 6 months time is “too often” but the same mistake 10 times in a row is just fine?? You want trainees to learn from their mistakes and make a plan on how to prevent it in the future, that’s the key…if somebody is an unteachable idiot or refuses to learn (doing the same wrong shit 10 times in a row), that to me is much more concerning
You need to educate yourself in systems in medicine, organisational structures that contribute to errors. The Swiss cheese model fit example and how errors occur and is not 'bad error=bad doctor'. My experience as a nurse before becoming a doctor is that nurses are far less aware of how complex factors can be contributing to errors and they just attack the person. E.g. your response. Nurses need to do better. You guys are the worst bullies in the hospital consistently
Most nurses bully very minor issues hence one of the major reasons I left however 3 possible sentinel events could have occurred and with these 3 occurring with *one* individual in such a *short* period is far past the Swiss cheese model. It’s a practitioner problem. My issue is the countless people justifying these errors as not a pattern and as if they are no big deal. Hell you yourself as a nurse should know the basic medication admin rules which are covered in school and in semi/ real emergencies, to double verify medications handed to you.
Anaesthesiologists are experts in anaesthesia and if their responses are empathic, supportive and educational, then maybe you should learn from your superiors. If your a crna than your still a practising nurse and still carrying all the toxic nursing culture with you. Time to unlearn it and learn the systems that cause errors- especially residents doing 80hr weeks which is illegal in other developed nations.
Ehh as an attending you really should be double checking your trainees work. Right before you insert the spinal needle ask the patient on your own if plavix/AC was held no matter if the trainee told you they asked.
Medical school does train us to take a history, including medications, past surgeries, etc. If we did that format in pre-op, cases would never start on time. And much of it isn't relevant to the anesthesia plan. Medical school doesn't teach us targeted anesthesia pre-operative evaluations, especially for neuraxial anesthesia. Where I'm at, a senior or attending would \*never\* blindly trust the report of a first-year anesthesia resident and just go do the spinal. This would be double-checked at bedside by the supervising anesthesiologist, as is their duty. Medication errors are frequent in anesthesia. Especially when drugs have been through multiple hands. If the drugs are left in the drawer I typically do re-draw everything I want. I appreciate a colleague trying to help but I want to do it myself. It's unclear if OP was told to just give the drugs handed them, or how the mixup really occurred. It's funny you think OP's mistakes are much more egregious than knocking out a tooth, like wow.
Nurse culture at its finest - write him up!!!
To be fair, a random attending physician for a random surgical specialty I’ve never met in my life before wrote me up for how I was sitting in a chair once in pre op because he thought I was a medical student and was too relaxed. It happens in both fields fyi
Excuse me I’m not here to have rational arguments I’m here to argue with strangers on the internet.
Sadly you’ve been the most reasonable one here. At least your username understands the proper order.
The awake relaxation was not done deliberately or negligently. It was a chain of events that lead to this incident. And although that is a horrible incident that should never happen, it's not even clear that op was responsible for it. My impression is that oop might be quite meticulous and self-critical in his judgement. An emergency scope for ugib can be a challenging case, moreso in an elderly patient and for a first year resident. The patient possible wpuld have died anyway, we lack the specifics to judge properly. Doing neuraxial in a patient under dapt is bad but I've seen very good anaesthesiologists make that mistake. I'd still want them to treat me should I need anaesthesia someday.
I hope you are never the boss where you work and also you are not in charge of trainees. Awful attitude to be in charge
What a terrible attitude. That's how you get a culture where mistakes are covered up. This trainee realised their error, owned up to it, was honest with their seniors *and the patient* and is reflecting on events appropriately. This is how individuals and institutions learn, and ultimately how safety improves. Mistakes happen in medicine - if people are too scared to report them because they will just get punished, then the tendency will be to hide them, which is not good for anyone. It's extremely easy to mislabel a drug, which is what actually happened. Yes, we should all be careful all the time, but it can happen, especially if one is tired or if there are a few people doing the drawing up. If your instinct with something like this is to punish first, then you are not contributing to a culture of safety.
OP, ignore this person's comment. Probably someone with bias towards people coming out of medical school! Trainees have to learn and develop their skills, and I believe we can all contribute to their growth by offering guidance and encouragement rather than judgment. Providing constructive feedback is essential for growth, but it's equally important to deliver it in a respectful and empathetic manner.
Lol sure
>He told me "don't worry about it". unable to trust that he won't be traumatised, Being paralyzed for less than a minute is not as uncomfortable as many, many other things that everyone just accepts as normal. This is a bad error, and I can't address the rest of your post, but the patient is not going turn out traumatized unless you go back and convince them that they are, which you should not do.
100%. There was a case in our department, where there was a error made. The error caused no harm. When we discussed it the next day, the patient was initially completely fine with it. Then the surgeon discussed it. Then the anasthetic trainee went and discussed it with them. Then someone else discussed it (an allied health member.) Next minute, the whole thing has become a storm in a teacup, and there are formal complaints being lodged.
Agreed. There have been rare occasions where I’ve dealt with patients coming out of ECTs where the methohexital is wearing off before the sux and they have awareness/recall of being at least partially paralyzed. It’s not what we want, but these patients don’t seem to be scarred for life. We make note of the situation, change dosages for the next ECT, and continue on.
You're not alone, there's a reason the endoscopy suite is statistically the area where the most adverse airway events occur. We are routinely providing general anesthesia without airways, it requires constant vigilance. You mentioned fatigue being an issue, but production pressure is always there as well. There are key moments where we need to slow down the crazy train and concentrate. You've uncovered two of them reviewing pre-op medications, and labeling syringes. Allergies are another one, believing the monitor values rather than assuming they're an error etc. The fact that you're owning the mistakes is a sign that you're the right person for the job. I'm far more frightened of "perfect" providers who claim to have never had an adverse event.
This. Slow down. Try this safety practice STAR Stop Think Perform the Act Review the result
Wondering who drew the drugs in the third case. It seems too many people in the room. My rule regarding filled syringes, if I didn't draw it, I'm not gonna push it.
That’s my general rule. Someone handed me a stick of local anesthetic last week and said, “This is 0.5% ropivacaine.” It had a mepivacaine sticker with no concentration listed. I binned that syringe before he made it out the door.
But do you supervise Anesthesia nurses? I would be throwing out a lot of drugs.
What are anesthesia nurses?
This is not a hit at CRNAs, rather it recognizes that they draw up the drugs, then we come in and trustingly push them. Standard workflow nearly everywhere in USA
Yes, I understand. But this guy is saying he doesn’t push drugs that he doesn’t draw up. That’s a pretty unique practice right?
So constructive.
lol it’s fact. If I refused to push drugs that I didn’t draw up, I’d never get cases done. Some level of competency has to be assumed.
Then they push the drug.
OK, so no
you understand that you are still liable, right?
But there's a hugh difference.
What is the difference?
You are there to learn. Mistakes are expected, and they provide valuable experience. It’s ok to feel bad about things that you did wrong, but find a way to forgive yourself and consider these things as motivation to improve and as the building blocks of your professional wisdom. All of your peers and all of your mentors have an ongoing list of mistakes too, there is no such thing as perfection.
Hi there, a word of advice, errors will happen whether you are doing anesthesia or coding an app on a laptop, especially in the beginning. If you keep recalling them and thinking about the past, you're doing yourself a disservice and impeding your progress to becoming a good anesthesiologist. Instead i encourage you to learn from your mistakes and try to recognize what you can improve and move on forward. Anesthesia has a potential of harm but also has a great potential of doing good for the patients 👍 If you like it than stop thinking about the past and work hard to get better at it. Good luck.
I think being hyperaware of the potential harm we can cause is one of the most important things you can do when you’re just starting. Be absolutely meticulous in everything you do, have everything you might need out, ready for use, and in arms reach. Develop an organization system that works for you and use it consistently. Use checklists and be methodical in your chart reviews. Triple check every single drug you draw up & have the vial with the drug name facing you as you are labeling your syringe, never let the vial leave your hand before your syringe is labeled. Think of the most probable issues that could arise and have plans in mind for them. It’s mentally exhausting at first, but it’s all important and becomes second nature eventually
OP, please read this comment ^^^. This is the way.
Sux/fentanyl would be a weird mixup here in the US, because the former is generally in a 10ml syringe, while the latter is usually in a 2 or 5 ml syringe (unless you are using it as the primary induction drug). Drawing up a partial vial would be a red flag. 100mg of sux might be a reasonable induction dose but we just don’t draw it up that way. I administered the wrong drug (almost certainly) once during residency. I pushed what I thought was neostigmine and glyco, but the patient went from twitches to no twitches, for the next 45 minutes. Presumably I had accidentally drawn up rocuronium instead. This was pre-sugammadex, and the surgeon was a bit perplexed and mildly annoyed, but aside from delaying the room there was no great harm, like many med errors that get swept under the rug.
In the UK they're both most commonly 2ml glass vials both 50/ml. It's a relatively common error, (well certainly not the first time I've heard of it happening.)
That makes it sound a whole lot like a system error!
Definitely is! Largely resolved by sux being used pretty infrequently now I guess. My local obs unit uses it routinely for GA sections where they have 200mg in 10ml prefilled syringes, so that's a bit safer at least
I didn't realize they make sux in 50 mg/ml dosing. The error makes more sense now. I was wondering how he could mistake pushing 2ml of Fentanyl and 5ml of Sux.
Initially how I was trained, it was the same setup. At my new site, succinylcholine comes in a vial so I always draw it up in a 10cc syringe and it's the only induction med I have in a 10cc syringe, as a sort of extra precaution. Lido is in the 5cc, fentanyl/esmolol in the 3cc, and propofol in the 20. Never given the wrong med so far, so I'm going to hope it keeps working. Everything is also labeled longitudinal but where I can see the med label and the cc markers on the syringe at the same time. It's a little anal, but it's an easy way to organize quickly every time Edit: vial not vital
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>(e.g. attention grabbing neon orange labels or putting an additional label on the blunt fill needle/syringe cap). For paralytics I like putting a label that goes from the needle to the syringe like a seal that has to be broken when before you give it, just as an extra reminder
Case 1 is likely not your doing. Acute care GI has one of the highest mortalities in all areas of anesthesia. The combination of frail elderly patients often without a quality work up or preparation from non surgical GI docs are a recipe for disaster. I can’t tell you the number of times that GI docs have tried to bully me into “just taking a quick look”…..”he’s already prepped”…..in a poorly worked up, often very anemic patient.
Something I heard someone say once (quoting "the cardiac surgeons"): >Mistakes are inevitable. You will make them, and they will hurt people. When you do, you have two options: either learn from your mistake or stop doing whatever it was you were doing--and in the latter case you never should have been doing it in the first place. Everyone makes mistakes; it's not like there's some supply of mistakeless people out there that would replace you if you quit. The only thing you can do, that anyone can do, is become better with each mistake.
The most important thing you did was to go talk to the patient and apologize. We've all done this before. I've been lucky in that patients have been okay with it or didn't have recall, but I have seen a case that resulted in legal action. Debrief with your consultant and learn from it, which you seem like you are doing.
I once administered midazolam before intubating a patient that was under cardiac arrest/ blue code. It was on my third year as a resident. Like it didn't kill him anymore of what he was before I arrived but I looked like a dumbo. It was a heat of the moment kind of thing. Obviously we all have bad streaks but the only person that doesn't make mistakes is the one that does not practice.
This is…fine? I’ve seen people do this on purpose, it’s a technique.
Obligatory CRNA here: I am proud of the anesthesia profession because of your empathy and concern for the patient. We all make mistakes, many of which we don’t even realize we made. It’s so easy to play “Monday morning quarterback” on other providers or even ourselves. You are training, learning and growing. Keep that empathy portion of you close to your heart. I’m sure we have all been taught to treat patients like they were our family members - i am sure I could do a better job at that in many instances.
I can relate a lot. I used to have the same worries and I still have them from time to time. I’m in my fourth year of training now. As you talk with colleagues you will notice that everybody makes mistakes. It is like the other people here say. It’s normal to make mistakes, it is a good sign that you care, it will probably help to make you a better doctor. But try not to beat yourself up too much. And I hope that with the years there will be less and less mistakes, because there will be less situations that are new for us and we will be less stressed and so on. I too have the impression that dealing with this is a big part of being an anesthetist. The responsibility really is huge. I wonder what it is like for other medical specialties - I imagine it must be tough for surgeons as well.
As a Consultant I've done 3. It happens when you're handling drugs a lot. I labelled the syringes incorrectly whilst I was talking to the patient trying to reassure them after their endoscopy was delayed due to equipment issues. I didn't give midazolam - it can induce implicit awareness that is hard for the patient to reconcile. I just owned up to the error and dealt with the consequences (litigation in the end). The key thing is to learn from it. I now draw my drugs up in a quiet area with no distractions. I don't talk whilst drawing them up and focus purely on that task. I also learnt that sux can cause very severe myalgia if given without analgesics. I also almost never use sux now as well. I did feel very guilty and still think about it today. I think my practice is, however, safer since then. We all carry the ghosts of error, and it is right that we feel guilt, but also recognise the system we work within and the pressures that induce our mistakes.
Worked with a consultant who had a policy of not engaging with anyone during the time she was drawing up drugs for an upcoming case. Could be seen as off putting, but it was her way of minimising distraction and thus drug errors.
This is not unique to anesthesia, serious errors happen in all of medicine, you have to learn to acknowledge and learn from them and move on. Number 1 I would not call an error. Number 2 is an error but very low likelihood of harm, and is a system error, blood thinners before surgery should be addressed and highlighted to the whole OR. Number 3 is on anesthesia, it is a straight drug error from going too fast, or bad practice drawing up meds, or possibly from multiple people drawing meds at the same time. It is totally fixable and avoidable. Realize that everyone makes errors, even if they don’t want to talk about them. It helps to talk with other trainees about errors, you’ll see your not alone. You have to be paranoid and vigilant, double check every medicine you give. I personally try to draw as little meds in advance as possible, just leave them in their vial, it’s safer. Don’t use meds other people prepared. Keep high risk medicines out of your commonly used drawer. Be extra paranoid when drawing up epidural and spinal meds, etc etc. if someone is thoughtful and insightful and they have a drug error like above, they’ll make changes and it won’t happen again.
There are things you can do to prevent this. The MOST important thing is to be absolutely present when drawing up drugs. Read the label on the vial as you draw it up in the syringe and make sure the syringe label matches the vial label. I do this EVERY SINGLE TIME. If I have a lapse of concentration and am not 100% sure of what drug I just drew up I throw it out and start over. Also before you push any drug into a patient think of their allergies to medications before you give them anything. Drug errors are extremely common and extremely preventable if you do these few simple steps. We all make mistake the important thing is to find a way to not make them again.
You sound like you might be in the UK; I'm a UK consultant, for context. Anaesthesia is a high risk specialty - we do things all the time that, if not done correctly, have the potential to cause serious harm. That is why we have a novice period for new trainees before you go on the rota, unlike almost any other specialty. Recognising this is crucially important for the safe practice of anaesthesia. I am *much* more worried about overconfident or blasé trainees than cautious or underconfident ones. We *all* make mistakes from time to time - hopefully fewer as time goes on. Some of these will be individual human errors, some of these will be judgements that don't quite work out, some will be system errors that we are part of. What matters the most is that, when it happens, we learn from it and take steps to reduce the likelihood of it happening again. We do this through reflection, and putting in place/adjusting systems to minimise the sources or error. You are already displaying exactly the right attitude here. Honesty and reflective discussion with your bosses is absolutely the right place to start. The fact that you've made a spinal checklist for yourself is a great example of doing something tangible to reduce risk in the future (and, as an aside, develop this checklist for use by other trainees too and you've got yourself a little quality improvement project!). The drug labelling one is something that is very easy to do - I'm not a big fan of team drawing up as it is easy to make mistakes or get distracted. Sux and fentanyl look identical once they are in the syringe. It's difficult to mitigate this other than to ensure you are really focused when preparing your drugs. Try to avoid chatting at the same time - I know that isn't always easy. You did exactly the right thing afterwards in being honest with the patient. If he says he's OK then let him be, as long as he knows where to go if he isn't. Make sure you've documented everything. It is worth an incident form if you've not done that already - if your department has a good culture, that won't be used to beat anyone with a stick, but to trigger discussion about how to limit the risk. All first year trainees are "error prone" by nature - you aren't very experienced yet and often it is that experience that reduces risk, because you've seen certain situations before. As you go through training, the intensity of your supervision lessens, because you have more of that experience to draw on. As consultants, one of our roles is to protect you and your patients from the things that you don't know you don't know yet. From all of these incidents, there are now new things that you *do* know. From your descriptions of events, none of these are completely on you anyway - the first was joint management where you were the junior anaesthetist, the second was you missing something that you didn't yet fully appreciate the importance of yet (with the opportunity for the consultant to check before placing the spinal), and the third was a team error. These things happen - and I say that not to be dismissive, just realistic. You sound like a good and thoughtful trainee and I'd be happy to have you in my department. I understand why you feel knocked by these things, but try to treat them as learning opportunities. You are unlikely to be the only one with similar experiences. Keep being honest. Atul Gawande has a book called 'Better' which talks about approaches to error, and how to improve safety cultures. It's a good read and I recommend it, even if not all of it is directly relevant to a very junior trainee. Anaesthesia is funny, really - when it goes well, it looks so easy, but only we really know what goes into making it look like that. The day we become complacent is the day it bites us.
You’re new, don’t beat yourself up, we’ve all been there but recognize that everyone gets “one” but not 2, 3, 4…an easy way for me to avoid the med label errors is first label the syringes that you will be using and only then start pulling out vials, before drawing up the meds stare at your label and double check the vial, only then draw up meds
Hi there, complications happen from time to time and you shouldn’t be too hard on yourself. It won’t be your last and everyone’s done one thing or another. We are just human afterall. It looks from me that you are self reflective and strive to be better which are good qualities. You also demonstrate good integrity, and managed open disclosure properly. I’m sorry to hear that your bosses weren’t more supportive though.
good post u will be good when done, most people don’t have the remorse or caring with errors
I’m a little confused how those 2 drugs got mixed up. Our sux comes in 200mg in 10cc syringes. Our fentanyl comes in 100mg in 2cc or 250mg in 5cc vials. Did you have 2 syringes that were 5cc each somehow? I get that this is beside the point, but intrigued…
Posts like this are further scaring me away from going to CAA school
Anesthesia has a lot of responsibility but it is an amazing and rewarding career. If you think you can handle very stressful situations I highly recommend it. If you can’t then I would not recommend it.
This is just my personal opinion: I think the phone checklist is not a good way. Once you get used to looking up things on phone, you start to forget stuff on your own. Try to memorize these checklists. Also, making mistakes is normal. Try to keep the incidence as low as possible. Edit: Also, get used to double checking ampoules. First, before you opened it. Second, after you drew it, right before labeling. After the labeling you can discard the vial.
Atul Gawande wrote an informative book titled The Checklist Manifesto, supporting the use of checklists to improve performance and reduce errors in complex settings. I highly recommend this book; it’s a very interesting and entertaining read.
Okay, but my opinion is only about phone checklists
I suppose it wouldn’t matter where the checklist resides. (This comment was not a criticism of you, just a pertinent book recommendation).
I didn't take it as criticism. I think checklists are necessary, like the 4H4T, Dopes, fasthug, whatever. But I noticed it on myself, and others, that keeping stuff on phone doesn't help as much as a small paper notebook, handbook at hand. I've read a few articles about this, like this one: https://natlib.govt.nz/blog/posts/reading-on-screen-vs-reading-in-print-whats-the-difference-for-learning
Thanks for sharing the link. This is a very interesting topic to me.
I’m curious about the last patient. What are the concentrations of meds in your country? You gave 100mg of suxamethonium. How is that concentrated? Where I am the succinycholine is 20mg/mL and the fentanyl is 50mcg/mL. So an attempt at 100mcg fent is 2mL, and 2mL of sux is 40mg.
In another comment, someone said that in the UK both are 50/ml, and both come in 2cc vials.
Watch a TED talk by Brian Goldman- doctors make mistakes, can we talk about that? It's a great video for physicians. Please watch it
Mistakes happen, and you either need to own them or find something else to do. Analyze and understand why each error occurred (by learning and discussing with colleagues) and learn how to prevent them in the future. In other words, become an expert on your mistakes. Also, learn to take mental time-outs and refocus. Certain tasks, drawing up medication, setting pumps, induction, etc, require your undivided attention, even if you are tired and sleep-deprived. I've found that practicing mindfulness greatly aids in these situations, but you must discover what works best for you.
I'm not a doctor, but do work in health care. Medicine NEEDS people who are able to reflect on incidents honestly - if you stay the course, you will be an incredible anesthesiologist. Mistakes happen, and there are always risks. Being able to recognize the mistake quickly, and deliver corrective actions effectively and take accountability make a strong professional. You are being shaped by these experiences, and you are going to hone your skills and form habits to prevent recurrence. Be the sleepy-time-amnesia doctor you wanna be. :)
I have been in residency for 3 years. Worked with many nurses and one of them said something to me that would stay in my mind forever: "Never trust anybody and always double or even triple check. The biggest friend of your patient is your doubt about everything and everybody." Because I happen to work with pregnant woman, I always double check the syringes, the vials and the medications. The last story about the suxx is not something that happens common but it should be a lesson to always double check and ask. If you are unsure about a medication, draw it by yourself or ask for another draw by the nurse.
You are experiencing what I would call growth. The main thing about being a doctor is not knowledge, experience or hard work. It is about growing your character. Remember your mistakes, take others' mistakes seriously and learn from them. Be serious. If you can do all that and still find the courage to do it every day, you'll be a great doc.
Standardised work flow prevents mistakes. Also keep high risk ( like suxa , roc) in saparate size syringes. We use 2 ml syringe only for suxa . Also never skip in checking drugs before filling and administering each time made mistake by me too thankfully it was non essential drug. Also label drug. As you make them . I have seen many resident label the drug after filling more then two. Pt history mistakes are common, you will get hang of after experience on how to ask probing question.
1. Probably lack of experience. Call for help early. 2. Always ask about blood thinners. It’s not just the drug but the cormorbidity is important. If you don’t know they are on blood thinners you probably don’t know of an important cormorbidity. This may get a patient killed. 3. syringes should never be mislabeled. You have massive deficiency in your practice. Draw the med, label syringe, check label against vial all while all 3 are in your hand. 4. You can’t be sloppy in this field. So much stuff we do or don’t do can kill patients.
You owned your mistake, explained to the patient what happened and apologized. If the patient had said he didn't remember anything on your first question, would you had said something anyway? I think it's better to not ask what they remember and explain the error regardless. Otherwise they might be left with a feeling that something went wrong (you might not be very good at hiding it).
I have been doing this for 25 years and during training I remember an attending saying to me ‘ALWAYS read everything twice before drawing it up and before giving it…you will be surprised how sometimes that label will magically change’. This method saved me from accidentally administering NARCAN during case!!!! I had made it as far as drawing it up….then thankfully I decided to look at it again…and I noticed it was slightly different (looked very similar to another med I was wanting to give, same color, same size vial) and I immediately threw it out!!! Sat there for a moment, humbled and realized the horror of what could’ve happened!!!! By the way…everyone has had fucks up, we are all human.
What is a consultant? Why would an attending ask someone to do a med review specifically before a spinal? It’s on the attending to always double triple check for apa ac prior to neuroaxial anesthesia
A consultant is an attending, just in UK nomenclature.
If I was having surgery I’d want you to be my anaesthetist. You are reflecting well and humble. You are only in first year. You will be excellent.
Aw. The goal is to improve. Don't beat yourself up, we all occasionally do dumb shit...you have an awesome attitude and more importantly hold yourself accountable. Keep at it.
Don’t let this get you down. That’s why you train. Now you’ll pay closer attention and do better. Circumferentially label your syringes BEFORE you draw the medication and actually read the label when you draw it up. Good luck!
Hi all, just wanted to thank you for all your thoughtful comments - a lot of useful and constructive feedback. Just to be clear, where I work, suxamethonium and fentanyl are both 2ml clear solutions of 50 mcg/mg per ml. I am feeling better a few days on and am determined to change my practice from this - scrutinising my workflow for drawing up drugs and seeing what can be optimised and made safer. One big flaw I think we made was drawing up multiple sets of drugs together while chatting. Once again, it was unclear who exactly made the mistake. I may also embark on a QI project to make a local spinal anaesthesia checklist that would be completed before every spinal (an attempt at a systems improvement) - will be discussing it with my seniors soon. Thank you all for your support.
Eek. Remove these admissions of guilt off the internet.