Articles  |   February 2020
A Case Report from the Anesthesia Incident Reporting System
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Pharmacology / Articles
Articles   |   February 2020
A Case Report from the Anesthesia Incident Reporting System
ASA Monitor 2 2020, Vol.84, 64-65.
ASA Monitor 2 2020, Vol.84, 64-65.
Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to Report incidents or download the AIRS mobile app at
Case 2020-2: All Hands On the Pump
A 10-yr-old boy scheduled to have I&D of an abscess of the foot in our sedation area. Sedation to be administered by one of the non-anesthesia (ED-trained) physicians. Plan was for propofol infusion. Propofol infusion set up by one of the unit nurses using a syringe pump. Small bolus of propofol given followed by infusion at 150 mcg/kg/min. After a few minutes, sedation M.D. noted patient becoming apneic and noted that a large volume of propofol had been administered. Pump check found infusion to be programmed at 150 ml/hr. Pump reprogrammed and procedure completed without any additional problems. Safety incident review conducted and noted that the nurse used the appropriate drug library and chose propofol but misprogrammed the pump in ml/hr. The provider had asked the nurse to set the pump to start at “150” without indicating the infusion mode. The sedation nurse was new and was not aware that propofol is commonly administered in mcg/kg/min. Manufacturer contacted to see if the pump could be reprogrammed to only allow mcg/kg/min as an option in the propofol library. We were told that they were aware of the issue but that some adult anesthesia providers use ml/hr as the infusion mode.
Drugs errors unfortunately still occur with some degree of frequency in anesthesiology practice. A prospective study of drug errors at a large academic teaching institution followed 277 procedures that included 3,671 medication administrations. Of the 3,671 doses, 193 (5.3 percent) were classified as an error and of those, 79.3 percent were felt to be preventable. There are many types of drug errors based upon the 5 Rights of Medication Administration: 1) right drug, 2) right patient, 3) right dose, 4) right route and 5) right time. In this case, the correct drug was being administered to the correct patient at the correct time via the correct route. The dose, however, was incorrect due to a programming error that resulted in an overdose of propofol.
Infusion pump errors are a subset of all drug errors and may result in either underdosing or overdosing. Infusion pumps are now commonplace in all O.R.s, and clinicians routinely handle a variety of medications and fluids that require precise administration by pumps rather than by gravity. While infusion pumps allow us to administer medications more precisely, the introduction of this type of technology introduces opportunities for error. We would hazard to postulate that many institutions have had a medication error that was caused by a misprogrammed infusion pump, as this report indicates.
Newer infusion pumps have drug libraries that can be tailored to each institution’s needs. These newer pumps set up guardrails for each medication to prevent both gross under- or over-dosing. Programming often requires the provider to enter a patient weight. Errors can and do occur at this stage of programming, which will result in a medication error. In some instances, infusion pumps can be pre-programmed to deliver a medication at a specific mode. For example, dopamine may be pre-programmed to only deliver in a mcg/kg/min mode. For some pumps or perhaps for some rarely used drugs, however, clinicians may need to enter an infusion mode such as ml/hr, mcg/min or mcg/kg/min. This type of situation is highly error-prone and, in this case, the sedation nurse programmed the propofol at ml/hr when the intended mode was mcg/kg/min. There are several possible remedies for this error. The first would be the use of clear, closed-loop communication in which the clinician overseeing the sedation would have specifically asked to have the propofol initiated at 150 mcg/kg/min. The nurse would, in turn, repeat back these instructions to ensure she heard and understood the rate.
A second potential remedy would be to have the pump prevent anyone from programming a propofol infusion in a mode other than mcg/kg/min. The report indicates that the manufacturer was contacted but would not reprogram the infusion pump to only allow this mode. We can confirm that this is indeed true and are alarmed that the manufacturer cited use of the ml/hr infusion mode among some clinicians as the reason for not making the change. The most recent FDA guidelines list all propofol infusion dosages in mcg/kg/min, and we would strongly endorse using this modality. The ECRI Institute listed infusion pump errors as the number-one potential hazard in its Top 10 Health Hazards for 2017. Infusion pump errors were the number-six hazard on their 2019 list.
A third potential solution is something known as interoperability between the EMR and the infusion pump. With this technology, the infusion pump and the EMR communicate with each other such that infusion pump orders entered in the computerized provider order entry system will automatically program the infusion pump, eliminating the potential for a programming error. The patient’s identification barcode, the drug barcode and the pump barcode would all have to be scanned before the infusion could be started. While this technology is promising and exciting, anesthesia providers do not commonly enter orders for infusions or for infusion dosage changes, nor do we commonly scan patient or medication barcodes prior to drug administration. Anesthesia practices and workflows would need to change in order to integrate this technology.
One should not assume that other infusion errors could not occur. Propofol is very distinctive in its appearance, but it is certainly possible for the incorrect drug to be loaded onto an infusion pump. Many hospital pharmacies have standardized syringe sizes for drug infusions such that all of the syringes look exactly alike, which could result in a syringe swap. If an anesthesiology practice prepares particular infusions (e.g., sufentanil) rather than having the pharmacy prepare them, the clinicians should agree upon a standard dilution/concentration so as to minimize the likelihood of an error. Mechanical errors can also occur. For example, in complicated procedures where many infusions are running simultaneously, it is possible for the incorrect medication to be running due to difficulty sorting out a tangled mess of lines, clamps, stopcocks and infusion ports. One suggestion would be to place multiple medication labels beginning with the pump itself and on the infusion lines all the way to the connection to the patient. There should be standardization of which clamp/stopcock will be used again to minimize the likelihood of a drug failing to be delivered. Modern pumps have alarms that detect obstructions to flow; very low flow rates that are commonly used in pediatrics may not alarm immediately.
One often-recommended safety check is to perform independent double-checks of infusions. Independent double-checks of all infusion pumps prior to initiation of the medication have been recommended by safety organizations and are often incorporated into hospital policies. The Institute for Safe Medication Practices defines an independent double-check as follows:
  • An independent double-check of a high-alert medication is a procedure in which two clinicians separately check (alone and apart from each other, then compare results) each component of prescribing, dispensing, and verifying the high-alert medication before administering it to the patient.
The exact process by which this should be performed should be clearly articulated to eliminate any assumptions and to provide granular detail. Independent double-checks will reduce errors caused by confirmation bias, a well-known phenomenon during which we tend to interpret or recall information based upon prior knowledge. The clinicians performing the double-check should also be familiar with the drug and the doses. In this case, the nurse was new and was unfamiliar with the manner in which propofol is administered. In situations where there is only a single anesthesia/sedation provider, there should be institutional agreement on who will perform the double-check with the provider.
Other potential intraoperative infusion may occur such as when infusion rates are changed during the course of the procedure. Current anesthetic practice does not typically offer a practical way to perform a double-check, especially if a rapid titration is being performed. Replacing an empty syringe often requires clamping of the infusion line, and errors have occurred when providers have failed to unclamp the line prior to re-initiating the infusion.
In summary, infusion pumps are common devices in O.R.s. Clinicians routinely use these devices in their daily practice, but while they provide accurate delivery of medications, they introduce potential opportunities for errors. Clinicians should use pre-programmed drug libraries when available, and independent double-checks of infusions should be considered prior to initiation of the medication to eliminate confirmation bias. Pump/EMR interoperability has the potential to reduce programming errors but may require changes to current anesthesia workflows.
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW . Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):25-34.
FDA. Propofol guidelines. Revised April 2017. Accessed November 8, 2019.
Emergency Care Research Institute. Top 10 health technology hazards for 2017. Published November 2016. Accessed November 19, 2019.
Emergency Care Research Institute. Confusing dose rate with flow can lead to infusion pump errors. Published September 26, 2018. Accessed November 19, 2019.
Institute for Safe Medication Practices FAQs. Institute for Safe Medication Practices website. Accessed November 8, 2019.
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