Call for ban follows horrific epidural error

[BellyBelly]

Call for ban follows horrific epidural error

Call for ban follows horrific epidural error
Julie Robotham
March 31, 2011

SKIN antiseptics should be banned completely from the sterile equipment table used during epidural procedures to prevent them being injected by accident, recommends an internal Health Department investigation ordered after a mix-up left a Sydney mother, Grace Wang, catastrophically injured.

Antiseptics should be distinctively coloured so they could not be mistaken for the saline solution injected into the spinal column to numb the pain of childbirth, says the Root Cause Analysis report obtained by the Herald.

And anaesthetic procedures should be standardised across all NSW hospitals to reduce the possibility a doctor or nurse misunderstanding the protocol.

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The report into the accident at St George Hospital last June also contains harrowing new details of how the two clear fluids - decanted into identical metal dishes - were switched while 32-year-old Ms Wang was giving birth to her son, Alexander.

She suffered severe neurological damage and remains in the hospital's rehabilitation wing.

Doctors realised a first attempt to introduce the catheter into Ms Wang's epidural cavity had failed when they noticed blood in the catheter, indicating it had hit a vein or artery, the report reveals.

When the anaesthetic team tried again to insert the catheter, they noticed the fluid had ''a slight pinkish tinge'' - which should have indicated it was the powerful antiseptic chlorhexidine.

Instead they assumed it was saline, believing the colour was ''due to the blood contamination from the previous first attempt'', and they went ahead with the procedure.

The doctor withdrew the catheter after Ms Wang called out in pain but by then eight millilitres of toxic antiseptic, mixed with saline from the first attempt, had been infused into her body.

Ms Wang, who remains disabled and in pain, told The Australian Women's Weekly this week: ''There have been times when I thought that it would be better if I was not here, so that [husband] Jason and Alex can go back to normal life.''

Ms Wang said she was envious of people, including a hospital-supplied nanny, who were bonding with her first child.

''I so want to feed my baby, but now he is living with the nanny and is so close to the nanny and not to me,'' she said.

The hospital investigation, finalised last September, found that all doctors and nurses who attended Ms Wang were properly experienced.

The anaesthetist was about to complete specialist training, none of the clinicians were tired and the delivery room was adequately lit.

The report's authors asked the Health Department to consider using coloured syringe plungers, different-sized syringes or sterile labels to distinguish fluids.

The authors also recommended that the department consider using antiseptics that were more visually distinctive than chlorhexidine as well as impregnated swabs instead of liquid antiseptic.

A NSW Health spokeswoman said the report recommendations had already been implemented at St George and Sutherland hospitals and would be considered in the development of statewide rules.

She said a policy on the safe measurement and administration of liquid medicines would be introduced to NSW public hospitals in May.

[*Efjay*]

I wondered what had happened with this lady. Poor family. Such a horrible mistake that has left the lives of many in ruins.

[Charlotte91]

Thats horrible. :-(

[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.

[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....

[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.

[Catastrophic]

I don't understand how this had happened. I read over the story a few times and try to think about the ward an the set up we have and tried to get my head around it.

Everything including saline flushes need to be checked be another RN. Now I to ask the question why wasn't the saline left in the contained and drawn straight into a syringe - I was of the understanding this was common practice? And you leave the saline vial on it until you use it. With any flushes? You certainly wouldn't be exposing it To the air and drawing it up from the tray????

And then to the antiseptic, it's pink! How is that not identified enough? I can understand why that Is in a tray.

This poor woman ;(

Love MN ;-)

[delphmoon]

It says they noticed it was pink and the doc figured it had been contaminated with blood. If they stopped for a moment and thought about it they could have prevented this mess.
And yes, 2 RNs check saline but the docs don't. Maybe they should!

[Saffy]

the stuff we used to use was clearish/pale pink, it is now bright pink (like beetroot juice)following the above (terrible) situation.

In my experience, all the fluids and equipment used are laid out on the sterile field, the antispetic is usually poured by the nurse into a pot and the injectable meds are drawn up in a sterile manner, into syringes, although I recall years ago seeing some anaesthetists pouring the meds ino a sterile tray- crazy in retrospect. Most of the epidural medications are now in vials which could only be drawn up with syringes. What a horrendous mistake, feel for the family so much

[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.