title: [Phenylephrine dosing error in Intensive Care Unit. Case of the trimester].
abstract: A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1mg in 10 mL). The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture. In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (<30 min) was developed and to close the communication gap through the adoption of communication techniques. The protocol was designed by physicians and nurses to standardize the administration of drugs with high potential for errors. To close the communication gap, repeated checks about saying and understanding was proposed ("closed loop"). Labeling syringes with the drug dilution was also recommended.
authors.affiliation: España.
mesh_terms: D003144:Communication Barriers; D004305:Dose-Response Relationship, Drug; D006801:Humans; D006973:Hypertension / Q000139:chemically induced*; D007022:Hypotension / Q000188:drug therapy / Q000451:nursing; D007362:Intensive Care Units; D008508:Medication Errors; D009730:Nursing Assessment; D010656:Phenylephrine / Q000008:administration & dosage / Q000009:adverse effects*; D019555:Physician-Nurse Relations; D011013:Pneumonectomy; D011183:Postoperative Complications / Q000139:chemically induced* / Q000188:drug therapy / Q000451:nursing; D013566:Sympathomimetics / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D013566:Sympathomimetics; D010656:Phenylephrine
keywords: Anestesia; Anesthesia; Drug errors; Errores de medicación; Patient safety; Seguridad del paciente