title: Accidental injection of patent blue dye during gynaecological surgery: Lack of knowledge constitutes a system error.
abstract: The authors report a case in which an intravenous injection of Patent Blue V dye instead of Indigo Carmine was given during routine gynaecological surgery. The patient presented with temporary arterial (spurious) desaturation and skin discoloration over a 48-hour period. Pharmacological differences between these dyes are described. Root cause analysis based on the ALARM (Association of Litigation and Risk Management) model is presented. The authors emphasise that use of this model should not be limited solely to describing and correcting well known systems errors such as working conditions or teamwork and communication. Furthermore, they conclude that insufficient knowledge must also be recognised as a systems error and as such should be sought out and corrected using similar strategies to those used to discover other contributory factors, without allocation of blame to any individual.
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, hôpitaux universitaires Paris-Sud, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France.
authors.forename: Edita
authors.initials: E
authors.lastname: Laukaityte
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, hôpitaux universitaires Paris-Sud, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France.
authors.forename: Marie
authors.initials: M
authors.lastname: Bruyère
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, hôpitaux universitaires Paris-Sud, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France.
authors.forename: Amanda
authors.initials: A
authors.lastname: Bull
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, hôpitaux universitaires Paris-Sud, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France. Electronic address: dan.benhamou@bct.aphp.fr.
authors.forename: Dan
authors.initials: D
authors.lastname: Benhamou
mesh_terms: D000369:Aged, 80 and over; D004396:Coloring Agents / Q000009:adverse effects*; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects*; D006801:Humans; D007044:Hysterectomy; D007203:Indigo Carmine; D019300:Medical Errors; D012394:Rosaniline Dyes / Q000009:adverse effects*
chemical_list: D004396:Coloring Agents; D012394:Rosaniline Dyes; D007203:Indigo Carmine; C008769:sulfan blue
keywords: Dyes; Indigo carmine; Medical education; Medication error; Methylene blue; Patent blue