Accidental injection of patent blue dye during gynaecological surgery: Lack of knowledge constitutes a system error.
Anaesth Crit Care Pain Med
; 34(1): 57-60, 2015 Feb.
Article
em En
| MEDLINE
| ID: mdl-25829317
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.
Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Corantes de Rosanilina
/
Procedimentos Cirúrgicos em Ginecologia
/
Erros Médicos
/
Corantes
Tipo de estudo:
Prognostic_studies
Limite:
Aged80
/
Female
/
Humans
Idioma:
En
Ano de publicação:
2015
Tipo de documento:
Article