BC PSLS met with Wrae Hill, Human Factors and System Safety, Interior Health (IH), to discuss medication error traps. They use the example of an anaesthetist who, during an emergency C-section, under time constraint, gave their patient the drug cisatracurium instead of succinylcholine. Both medications are used for muscle relaxation and paralysis, however cisatracurium has a much longer duration of action.
Cisatracurium was available in the Labour and Delivery Suite, but the vial cap of cisatracurium had previously been blue, yet today it was red. This ‘medication error trap’ – a recurrent situation that predictably snares a large number of different people – resulted in the patient having to be ventilated for longer than anticipated.
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