Call for ban follows horrific epidural error
Call for ban follows horrific epidural error
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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.
