Case update: epinephrine death in Florida

From the December 4, 1996 issue

The January 31, 1996, issue of ISMP Medication Safety Alert! discussed the case of a 7-year old boy who died following what should have been routine surgery to remove scar tissue and a benign tumor from his left ear. Further details and the hospital's reaction to the devastating news that a medication error was responsible for the child's death were openly provided by staff from Martin Memorial Hospital, Stuart, FL, during an emotional discussion of the case at the Examining Errors in Healthcar e Conference (Annenberg Center in Rancho Mirage in October). The hospital's anesthesiologist, risk manager and chief executive officer participated as did the family's law firm. Each presented his/her perspective of the events. The child's parents gave permission for the discussion.

During an elective tympanomastoidectomy, the child received an injection of what was supposed to be lidocaine 1% with 1:100,000 epinephrine. His heart rate and blood pressure soon rose dramatically, but after immediate treatment, his vital signs stabilized, and the surgery proceeded. About 10 minutes later, his heart rate and blood pressure fell, and the child went into cardiac arrest. Full CPR was initiated, and after an hour and a half of resuscitation, he was stabilized again, but remained comatose. He subsequently died the next day.

Initially, it was assumed that the child suffered a profound reaction to injection of the local anesthetic. However, laboratory examination of solution specimens pointed to something other than lidocaine with epinephrine being in the syringe.

An exhaustive investigation of the process used to prepare solutions for use within sterile fields led to the discovery of how the error took place. Not unlike most hospital operating suites, in order to preserve the sterile field, medications were first poured into sterile cups and then drawn up into syringes when needed. In this case, epinephrine 1:1000 was accidentally poured into a cup labeled "lidocaine with epinephrine." A specimen cup that should have been used for soaking Gelfoam® pledgets with epinephrine, to control local bleeding, was never filled. The scrub tech (using a sterile syringe) drew up 3 mL from the cup labeled lidocaine with epinephrine, which actually contained epinephrine 1:1000. That syringe, containing approximately 3 mg epinephrine, was used to infiltrate the ear, causing the child's arrest.

While the evidence confirmed that the child's death was due to a faulty process, finding out the real reason why he died and correcting what went wrong will help to prevent similar errors. The hospital has redesigned the method used for transferring and handling medications between nonsterile and sterile fields in a surgical environment. It includes labeling everything and having two people verify the contents and labels before administration. They have worked to simplify the procedure and eliminate hazards, such as replacing a 30 mL vial of topical epinephrine with presoaked epinephrine pledgets in the sterile field. The key lessons learned from the investigation include the need for eliminating steps, simplifying procedures, and preserving samples when errors occur. The cause of the child's death may not have ever been known had the samples not been saved.

We applaud the hospital for coming forward with the details of the case because it provides valuable lessons for every institution. As stated by the risk manager, a significant amount of time and effort was devoted to the improvement of procedures used in the surgical suite so as to avoid the possibility that this type of incident would ever recur. Clearly, she didn't mean just at Martin Memorial.

Martin Memorial Hospital has given ISMP permission to mail a copy of their redesigned procedure for preparing drugs for use in sterile fields. For a copy, please send us a self addressed stamped ($1.10) 81/2 x 11 business envelope marked "Surgical Protocol Request." [A,D(surgeons, anesthesiologists),N, P,Q].