Call for ban follows horrific epidural error

[briggsy's girl]

i can't understand what the process was that they were following - how can it be ok to put the saline into an open tray if it's going to be introduced into the spine? it should be drawn directly from a clearly marked vial into the syringe and then into the catheter.

ok, so i'm no anaesthetist obviously - but i've studied medical science in a pathology sense, and you just don't set yourself up for mistakes like this. proper aseptic technique should avoid double/triple handling of anything to ensure it remains sterile at all times - i just can't work out why the saline needed to be decanted into a tray in the first place!

this is just so frikken sad. it was a stupid mistake but people that should have known better - and i agree totally with the recommendations

[Kazzo]

ok, so i'm no anaesthetist obviously - but i've studied medical science in a pathology sense, and you just don't set yourself up for mistakes like this. proper aseptic technique should avoid double/triple handling of anything to ensure it remains sterile at all times - i just can't work out why the saline needed to be decanted into a tray in the first place!

This is what I was wondering too. I feel so sorry for this lady and the heartache she has for her son.She has been robbed of her first ever moments with him.

[Tuesday's Child]

i can't understand what the process was that they were following - how can it be ok to put the saline into an open tray if it's going to be introduced into the spine? it should be drawn directly from a clearly marked vial into the syringe and then into the catheter.

Exactly!

I'd been wondering how this woman was doing. It's so sad she and her son haven't been able to bond.

[delphmoon]

I think this is why now (as this occurred last year) the antiseptic is in a vial and is drawn up into a marked syringe.

[Mum2SweetCs]

I think her DH was on this very forum quite a few months ago before the news broke out.

Definitely feel so sorry for the family, so sad esp when it could have been soo easily prevented.

[Just Me]

I think her DH was on this very forum quite a few months ago before the news broke out.

I remember reading her story on here as well ... her DH posted it.

It is very sad. My heart goes out to this family.

It's unfortunate that they have to wait for mistakes like this before the risks are assessed. To me, it seems fairly logical and practical that fluids would need to be marked some way so you can tell them apart. Especially when injecting something into a person's spinal spaces.

[briggsy's girl]

I think this is why now (as this occurred last year) the antiseptic is in a vial and is drawn up into a marked syringe.

yeah but 2010 and not following proper aseptic technique??? if it is drummed into uni students when they're working in labs where the worst that can happen is contaminated results, what the hell was going on here? why isn't AT LEAST the same standard required here?

sigh - a woman has been seriously injured for life, both physically and psychologically. a baby boy is never going to have the mummy he should have. a family has been forever screwed up because of a stuff up that could have very easily been avoided

[MusicLover83]

This had me scratching my head too.

Thanks for the update. I'd been wondering how she was doing. I wish her all the best in her recovery and rehab.

[tellytubby]

Oh god that poor woman

[delphmoon]

yeah but 2010 and not following proper aseptic technique??? if it is drummed into uni students when they're working in labs where the worst that can happen is contaminated results, what the hell was going on here? why isn't AT LEAST the same standard required here?

sigh - a woman has been seriously injured for life, both physically and psychologically. a baby boy is never going to have the mummy he should have. a family has been forever screwed up because of a stuff up that could have very easily been avoided

I absoloutly agree that it is very unfortunate for the woman- it would be horrendous.

I don't think aseptic technique really has much to do with it as aseptic technique is about reducing contamination. This is more to do with labelling of substances in a more people friendly manner in order for it to be correctly identified.

For instance- potassium (which can cause serious SERIOUS cardiac issues when used inappropriatly) used to be kept in the same color and size vials as Saline...there were (serveral) occasions where potassium was used to flush IV lines instead of saline resulting in cardiac arrest of the patients. From then on Potassium was produced in red vials therefore significantly reducing human error and ofcourse increasing patient safety.

ITs absolutly awful to lose a love one or suffer trauma as a result of medical intervention- (I have lost 2 family members through this) but to see that medical science etc then go on and make changes to prevent (or reduce) it from happening again is at least better than doing nothing.

Hopefully this kind of thing never ever happens again.

[RhiChiChi]

I read an article in a womens magazine & they said that the antiseptic was coloured pink....

[briggsy's girl]

I don't think aseptic technique really has much to do with it as aseptic technique is about reducing contamination. This is more to do with labelling of substances in a more people friendly manner in order for it to be correctly identified.

i guess that was part of my point - i used aseptic technique as a reference, but the fact is that they contaminated that syringe in a most horrific way. i don't understand why the saline needed to be decanted into the tray - if it's going to be introduced into the spinal column, it should be handled in the most sterile of ways and decanting and then drawing the fluid up adds a step where contamination can happen. it seems ridiculously risky to me in light of the fact that a lab tech is HAMMERED about not double handling anything, not leaving anything to risk kwim?

i'm just really saddened by this.

[Snacks]

My first thought when I read the title was that someone had called for a ban of epidurals
Jokes aside, I really feel for her too. Mistakes like this are too horrible for everyone concerned.