Here, the case was settled against the orthopedic surgeon. The hospital has vicarious liability for the circulating nurse as an employee of the hospital. The plaintiff alleged that the use of the multidose vial was risky, and that the nurse did not perform an adequate time-out procedure before the error. This procedure is designed to give nurses protected time, free from other distractions, within which to manage and administer medications. The concept of protected time seeks to minimize errors of medication administration by giving nurses dedicated time to concentrate only on medications without the usual distractions from clinicians, other patients, telephone calls, pages, and the like. This is important, because a clinician’s prescribing or ordering error is often detected (by pharmacists or nurses, respectively). Generally, when a nurse administers a medication, there is no automatic “second pair of eyes” to review his or her action.
In this instance, however, the opposite situation existed: The nurse prepared the medication, and the physician administered it. The plaintiff’s contention was that the nurse mislabeled the medication, and the plaintiff was able to prevail at trial on this theory.
Interestingly, the plaintiff likely took the opposite position with the physician to obtain settlement before trial—that is, that the nurse correctly labeled the syringe, but it was inappropriately administered by the physician. After settling with the physician, the plaintiff was free to change the theory of the case—placing blame with the nurse and hospital. At trial, with an injured plaintiff and no clinician to blame, the jury found the plaintiff’s position credible and found the nurse responsible.
If there was no indication for 9 mL of epinephrine 1:1,000 to be placed on a tray next to bupivacaine with epinephrine 1:200,000, the jury would believe the medication was mislabeled. While epinephrine is often used to increase visualization during arthroscopic surgery, it is typically added to the irrigation solution (eg, 1 mL epinephrine 1:1,000 added to 3,000 mL of irrigation fluid). From the facts given, it is unclear whether the undiluted epinephrine 1:1,000 was kept within the surgeon’s reach. If so, this was a dangerous practice pattern that could have been recognized and the outcome prevented.
Confusion can lead to use of an incorrect concentration of the correct medication. This is particularly true with epinephrine—a substance with a built-in, tenfold fatal error potential. Epinephrine 1:1,000 (generally used for subcutaneous administration) can have disastrous consequences when given in place of epinephrine 1:10,000 (generally administered by IV). Several fatal and near-fatal cases have been reported involving this error. Epinephrine 1:1,000 in 30-mL vials has been specified for its overdose potential. Consider replacing these vials with 1-mL ampoules, and if this is not feasible, consider applying a warning label: “not for IV use without appropriate dilution.”
In cases in which similar medications are used in close proximity, consider applying a use-based label in addition to that showing dosing/concentration. For example, try labeling the syringe of epinephrine 1:1,000 “for subcutaneous/endotracheal use only” versus epinephrine 1:10,000, “for intravenous use.”
In whatever setting you practice, do your part to ensure that staff is specifically alerted to the hazard of potentially fatal epinephrine concentration errors. A life saved by preventing an error is a life saved. —DML