The Nature of Error

Abstract

An anesthesia resident physician in his second year of training anesthetized a 76-year-old patient scheduled for a laryngectomy and bilateral neck dissection. The medical history revealed coronary artery disease and liver cirrhosis. As a result of the associated coagulopathy, the surgeon had difficulty achieving adequate hemostasis and therefore repeatedly applied epinephrine-soaked swabs to the surgical site. The undiluted epinephrine was rapidly absorbed into circulation and caused sinus tachycardia and polymorphic premature ventricular contractions. Unaware of the surgeon’s use of undiluted epinephrine, the resident did not attribute the PVCs to the hemostatic treatment and hence did not urge the surgeon to stop the application. Instead, he decided to treat the arrhythmia with an ampule of lidocaine. Distracted by the ECG, he did not pay close attention and mistakenly used an ampule of metoprolol instead of lidocaine 2%. This drug error was facilitated by the fact that both ampules, adjacent to each other in the anesthesia cart, had similar labels.