reported: Sonntag, 16. Januar 2000
This is the short description of the incident:
| 69 YR FEMALE IN FOR ROUTINE TEE TO DETERMINE FEASIBILITY OF VALVE REPLACEMENT. SEEMINGLY UNEVENTFUL TEE PROCEDURE. PATIENT RETURNED VIA EMERGENCY TRANSPORT, 2 HOURS AFTER RELEASED FROM TEE. XRAY SHOWED 1CM PERFORATION OF ESOPHAGUS. ENSUING COMPLICATIONS/PROCEDURES: INFECTIONS, INTERIOR DRAINAGE, THORACOTOMY, MULTIPLE INTUBATIONS, J/G-TUBES INSERTION, ELEVATED DOSAGE OF PROMAXIN. HOW COMMON IS PERFORATION OF THE ESOPHAGUS DURING TEE, AND HOW LIKELY IS IT THAT THE PHYSICIAN PERMORMING THE TEE WOULD NOT REALIZE IMMEDIATELY THAT A PERFORATION OF THE ESOPHAGUS HAD OCCURED? |
- This is the description of the management:
| PATIENT HAS BEEN HOSPITALIZED AS A RESULT OF THIS INCIDENT FRO 20 DAYS AS OF 1/16/00 |
Potential Severity : potentially permanet morbidity
-
outcome : Unplanned hospitalisation of an out-patient.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 16. November 1997
This is the short description of the incident:
- This is the description of the management:
Potential Severity : transient damage with complete recovery
-
outcome : Patient dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 16. November 1997
This is the short description of the incident:
- This is the description of the management:
Potential Severity : transient damage with complete recovery
-
outcome : Patient dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 2. November 1997
This is the short description of the incident:
| Pt. scheduled for ambulatory liposuction under local anesthesia Wheal of carbocaine - Pt. becomes restless. Sedation as above given I.V. Cough, opisthotonus, seizures, loss of conciuousness, midriasis, death At autopsy, only abnormal finding has been a remarkable increase of cerebrospinal fluid (on removing the encephalus suirted about at 2 meters) |
- This is the description of the management:
| Endotracheal Intubation + 100% oxygen + ambulance to transport pt. to local hospital |
Potential Severity : ...
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 26. Oktober 1997
This is the short description of the incident:
| FEMALE,16, ELECTIVE ORL SURGERY FOR MAXILLARY SINUS - (CALDWEL LUC ) ASA I,INDUCTION : MASK VENTILATION WITH OXYGEN THEN THIOPENTAL+LEPTOSUCCIN, TRACHEAL INTUBATION,HALOTHAN 1.3% VOL. WITH OXYGEN AND NITROUS OXYDE 50% AFTER SURGERY LASTING 1 HOUR,HALOTHAN EX. VENTILATION WITH 100 % OXYGEN.aFTER RETURNING OF REFLAXES (SWALLOWING,COUGH),SPONTAN VENTILATORY DRIVE , EXTUBATION. AFTER EXTUBATION PATIENT UNABLE TO VENTILATILATE SPONTANESLY. ATTEMPT WITH 100 % OXYGEN VIA MASK,HEIMLICH MANEVOUR WITH NO SUCCESS. INSPIRATORY STRIDOR,ASSUMING LARINGOSPASM, PUPILS DILATED, NO CONSCIOUS, BLUE LIPS,BLUE EARS AND FINGERS, ECG SHOWING BIZARE AND WIDE QRS COMPLEXES. GIVEN SUCCINILCHOLINE AND THAN ECG SHOWD VENTRICULAR FIBRILATION.REINTUBATION, CPR, ADRENALINE VIA ENDOTRACHEAL TUBE,DEFIBRILATION 300 j. AFTER RETURNING CARDIAC RHYTHM VITH A LOT OF POLYMORPH VENTRIVULAR EXTRASYSTOLAS GIVEN XYLOCAINE I.V.40 MG BOLUS,AND IN CONTINUOUS INFUSION WITH RINGER LACTAT. VENTILATION WITH 100 % OXYGEN, PUPILS NARROWING.AFTER 35 MIN. EXTUBATION.NO NEUROLOGICAL SEQUELLE. |
- This is the description of the management:
| SUCCINILCHOLINE REINTUBATION, CPR, ADRENALINE VIA ENDOTRACHEAL TUBE,DEFIBRILATION 300 j. AFTER RETURNING CARDIAC RHYTHM VITH A LOT OF POLYMORPH VENTRIVULAR EXTRASYSTOLAS GIVEN XYLOCAINE I.V.40 MG BOLUS,AND IN CONTINUOUS INFUSION WITH RINGER LACTAT. VENTILATION WITH 100 % OXYGEN, |
Potential Severity : death
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 19. Oktober 1997
This is the short description of the incident:
| Patient without any personal or familiar antecedents of Malignant Hiperthermia. He had never received anesthetics before the incident. During the surgery he developed taquicardia and hipercapnia. Posteriorly his temperature rised from 36° to 41° accompanied of muscular contracture. The arterial blood gases showed respiratory acidosis (pH 6,84 - PaCO2 210 - EB -6 PaO2 86 with FiO2 100%) |
- This is the description of the management:
| We treated the patient following the protocols of the Malignant Hiperthemia Association of the U. States. (we don´t work in USA) The patient showed a signs of recovery from the crisis after the loading dose of dantrolene. He also received an infusion of this drug for the first 24 hours who followed the crisis. The patient was in ICU for 48 hs. No complications. No repeated episodes of MH. |
Potential Severity : death
-
outcome : Unplanned ICU-admission.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sonntag, 12. Oktober 1997
This is the short description of the incident:
| Ten minutes after child birth during well accepted epidural anaesthesia for caesareal section, sudden evidence of pulmonary edema and supraventricular tachycardia. The event was preceded by a light hypotension treated succesfully with low dose of ephedryne (1/10). After three hours of intensive care (orotracheal intubation and pharmacological intensive treatment) the pt died. The autopsy showed a misknown pheocromocytoma of 8 cm of diameter. |
- This is the description of the management:
Potential Severity : death
-
outcome : Death.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag, 6. Oktober 1997
This is the short description of the incident:
| Pt was an unexpected difficult intubation. Three laryngoscopic attempts were made and on the third, a bougie was used to facilitate intubation. On POD 3 pt saw ENT and was noted to have esophageal perforation on Barium swallow. |
- This is the description of the management:
Potential Severity : potentially disabling morbidity
-
outcome : Unplanned ICU-admission.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Mittwoch, 1. Oktober 1997
This is the short description of the incident:
- This is the description of the management:
Potential Severity : ...
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Freitag, 19. September 1997
This is the short description of the incident:
| ASD II surgery, routine case. Same day new isoflurane vaporizer was fitted to the heart-lung machine, between the flowmeter unit and oxygenator. Anaesthetic nurse did not close vaporizer after refilling. Perfusionist failed to notice smell of isoflurane. During full bypass surgeon noticed dark blood and alerted anaesthetist, who immediately checked the system and found open vaporizer (Cyprane Mark3). Patient' temperature was 32 C. Patient recovered completely. The heart lung machine has not been fitted with on-line oxygen analyzer. |
- This is the description of the management:
| The vaporizer was closed and manual ventilation of the lungs started. After weaning from the bypass patient received 1 g mannitol and penthotal sedation and ventilation for 24 hrs. |
Potential Severity : death
-
outcome : Outcome not affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Mittwoch, 17. September 1997
This is the short description of the incident:
| Asystole during laringoscopy for resection of laringeal mass.3o minutes post induccion,no muscle-relax, only estimulation quirurgical. |
- This is the description of the management:
| atropine 1 amp iv no response,next atropine 3 amp iv response. |
Potential Severity : transient abnormality unaware to the patient
-
outcome : Outcome not affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag, 15. September 1997
This is the short description of the incident:
| four week old baby with pyloric stenosis. Rapid sequence induction with criciod pressure. Resident anaesthetist unable to intubate patient on first attempted, tthen unable to ventilated via face mask resultinting hypoxia. Non resident anaesthetist took over airway but still unable to ventilate initially until criciod pressure release. Desaturation to 20% for 20 seconds. No adverse outcome. |
- This is the description of the management:
| Release of criciod pressure and repostioning of head and neck. |
Potential Severity : transient abnormalityunaware to the patient
-
outcome : Outcome not affectedby incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag, 8. September 1997
This is the short description of the incident:
| When a gave atropine/neostigmine in order to reverse the action of non-despolarizant muscle block my pcte became hypertensive(200/140mmhg) and Tachycardic(140bpm). At the same time, I saw in the EKG(D2) supra ST segment. Than, I recheck the ampoules and realize my mistake(I gave her 0.75mg of atropine and 1mg of epinephrineplus 03mgof neostigmine). After 10 minutes the vital signs were normal and patient woke up without any damage. |
- This is the description of the management:
| Ventilation with O2 100% |
Potential Severity : death
-
outcome : Unplanned ICU-admission.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag, 1. September 1997
This is the short description of the incident:
- This is the description of the management:
Potential Severity : ...
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Samstag, 23. August 1997
This is the short description of the incident:
| Heavy blood loss during a radical prostatectomy called for a pressurized rapid infusion system. When the bloodpressure was restored someone connected an infusion bag with (perhaps) 100 ml of air in it to the pressurized rapid infusion system. This air filled the systems tubig and some amount entered the patients circulation. This caused a second sudden drop in bloodpressure and end-tidal CO2. Because of the drop in CO2 the problem was quickly recognised. The system was disconnected and a dopamine infusion was started. Within 2 minutes the circulation was restored. Post-operatively there were no further problems and the patient recovered without suffering any damage. |
- This is the description of the management:
| 100% oxygen, fluid infusion and dopamine |
Potential Severity : transient abnormality unaware to the patient
-
outcome : Outcome not affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Mittwoch, 13. August 1997
This is the short description of the incident:
| Female patient, difficult to intubate, has had a apnoea and perhaps a laryngospasm with inability to open mouth after extubation. The patient in fact extubated herself during excitation. After 100% Oxygen ventilation with high pressure and mask the patient recovered and was transmitted to the ICU for surveillance. The postoperative chest radiography showed a pulmonary edema of the left lung only. We re-intubated the patient, who got more and more dyspnoic, about 3 hours after extubation. The bronchoscopy showed edematous fluid in the lower airways but no sign of blood or aspiration. The patient remained intubated and breathing CPAP. 24 hours later a severe ARDS developped and extubation remained impossible. during the next days the ARDS got more and more severe and pressure-controlled ventilation and kinetic therapy got almost impossible. On day 10 an anuric kidney failure developped and on day 11 the liver failed and the patiend had DIC. The patient died on day 11 in the ICU. Autoptic findings showed severe ARDS with multiple organ failure and signs of old aspiration in the RIGHT lung! The initial pulmonary edema on the left was interpreted as negative pressure pulmonary edema due to either laryngospasm or movement of the orotracheal tube into the rigth main bronchus during the excitation. |
- This is the description of the management:
| as described above: 100% oxygen ventilation with mask and reintubation on ICU after detection of the pulmonary edema as well as bronchoscopic suction of the edematous fluid containing airways (pH 8). |
Potential Severity : death
-
outcome : Death.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Samstag, 9. August 1997
This is the short description of the incident:
| Pacient developed tonic-clonic convulsions after a sinlge shot bupivacaine\fentanil epidural.Was administered suxinilcoline,intubated,ventilated with 100%oxygen ,and discharged tothe ICU. Went out of the ICU 12 hs later without other events Newborn ok, Apgar 5-9-10 |
- This is the description of the management:
Potential Severity : death
-
outcome : Unplanned ICU-admission.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Samstag, 26. Juli 1997
This is the short description of the incident:
- This is the description of the management:
Potential Severity : ...
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Mittwoch, 16. Juli 1997
This is the short description of the incident:
| Patient with disseminated oat-cell lung cancer was schedule for a Pericardiostomy with local anesthesia and monitoring. He developed abrupt hipotension with jugular turgency. The anesthesiology decided to general anesthesia and intubated with etomidate and succinilcoline. After that, the airway pressure became high and ETCO2 rised. The surgeon checked for pericardial tamponade or pleural effusion, but he didn't find that. He decided to performed a fiberoptical broncoscopy and find a occlusion by tumor 03 cm above carina with a valve mechanism, that probably increased with muscle relaxant |
- This is the description of the management:
| Ventilated with high frequency and low tidal volume |
Potential Severity : potentially permanet morbidity
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Mittwoch, 16. Juli 1997
This is the short description of the incident:
| Patient with disseminated oat-cell lung cancer was schedule for a Pericardiostomy with local anesthesia and monitoring. He developed abrupt hipotension with jugular turgency. The anesthesiology decided to general anesthesia and intubated with etomidate and succinilcoline. After that, the airway pressure became high and ETCO2 rised. The surgeon checked for pericardial tamponade or pleural effusion, but he didn't find that. He decided to performed a fiberoptical broncoscopy and find a occlusion by tumor 03 cm above carina with a valve mechanism, that probably increased with muscle relaxant |
- This is the description of the management:
| Ventilated with high frequency and low tidal volume |
Potential Severity : potentially permanet morbidity
-
outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag, 14. Juli 1997
This is the short description of the incident:
- This is the description of the management:
| CODE BLUE CALLED IN O.R. |
Potential Severity : potentially disabling morbidity
-
outcome : Major morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Samstag, 12. Juli 1997
This is the short description of the incident:
| postoperative evidence of ulnar nerve lesion |
- This is the description of the management:
| elettrostimulations |
Potential Severity : potentially disabling morbidity
-
outcome : Minor morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Dienstag, 1. Juli 1997
This is the short description of the incident:
| 12 hr craniotomy to remove large parasagital meningioma. Pre op MAP approx 90 mmHg. No episodes of untreated hypotension during the case, MAP kept >70 mmHg. Pt failed to arouse post-op. Subsequent CT and MRI POD3 showed bilateral basal ganglia infarcts. Pt transferred to long term rehab facility with poor prognosis. |
- This is the description of the management:
| expectant management |
Potential Severity : potentially disabling morbidity
-
outcome : Major morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Dienstag, 3. Juni 1997
This is the short description of the incident:
| Septic patient transfered to the ICU after abdominal CT-scanner. Patient was hooked on the ICU respirator and the ICU nurse was instructed to ventilate him with 10 x 80o ml, FIO2 = 0.5. As the ICU resident and the ICU nurse were informed about the patient, patient became extremely hypertensive (240/120). As the patient was quite awake, ICU resident ordered some midazolam. |
- This is the description of the management:
| Looking at the respirator setting, I noticed the nurse had switched the ventilation mode to pressure support... It turned out the patient was awake, but still paralysed (pancuronium)and could hardly breathe. Two minutes after switching the ventilator mode to IPPV, pressure back to normal. |
Potential Severity : death
-
outcome : Patient dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Wendsday, 28. Mai 1997
This is the short description of
the incident:
| Probable massive air embolism following use of rapid auto-transfusion device. Reservoir bag of auto tranfuser was filled from a cell-saver device, and so the reservoir bag had approximately 500ml of air and 500 ml of processed cells in it. After the blood had run in, the rapid transfuser emptied all the air into the patient in a few seconds, and a cardiac arrest followed. Attempted resuscitation not successful |
- This is the description of the management:
| ACLS protocols |
Potential Severity : death
- outcome : death.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Sunday, 25. Mai 1997 This is the short description of the incident:
| During induction, we wanted to suction secrets out of the pharynx, but the suction did not work because the surgical technician used the suction device for the thoracic drainage |
- This is the description of the management:
| exchange of the suction device |
Potential Severity : potentially permanet morbidity
- outcome : Outcome not affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Freitag, 23. Mai 1997 This is the short description of the incident:
| Patient was scheduled for emergency c-section. Obstetrician and anaesthetist misunderstood each other selecting the OR. So the patient and the obstetric team ended up in one OR, while the anaesthesia team waited in another. |
- This is the description of the management:
| Anaesthesia team hurried to the OR with the patient. |
Potential Severity : potentially permanet morbidity
- outcome : Patient dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Friday, 2. Mai 1997 This is the short description of the incident:
| 40 year old woman with mild asthma well controlled on ventolin/bricanyl inhalers for elective thyroidectomy.Routine general anaesthesia with propofol, pethidine,atracurium and isoflurane. Easy intubation with 'BIVONA'armoured latex endotracheal tube size 8.0;tube and cuff checked prior to anaesthesia.About 20 minutes after intubation and with the operation well underway[one side of the gland had been removed], the circuit pressure had increased to 60 cm. of water and a leak of gas could be heard from the airway.A few mls. of air was then added to the cuff, and then the ventilator pressure alarm sounded. On attempting to ventilate the patient by hand ,complete obstruction was encountered.No wheeze was heard on chest auscultation and the po2 was falling rapidly. |
- This is the description of the management:
| Anaesthesia ceased and 100% O2.Endotracheal tube removed and re-intubation with a portex tube and ventillation was then possible.On inspection,the tip of the tube was very soft and could be easily folded back on itself to obstruct the end hole.The cuff could be pulled along the long axis to occlude the side hole.The manufacturers recommendation is that the tube is safe for re-use after sterilization. |
Potential Severity : transient abnormality unaware to the patient
- outcome : unaffected by the incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Monday, 28. April 1997 This is the short description of the incident:
| 5 days after a difficult epidural cath placement for trombectomy at popliteal level, followed at day 3 by urokinase infusion,up to 1.800.000 IU/ day,paraplegia occurred. Anesthesist was called on day 1 for surgery and cath positioning, and on day 6 ,after incident |
- This is the description of the management:
| Neurosurgeon consulting. CT scan , MR imaging and emergency decompressive laminectomy |
Potential Severity : potentially disabling morbidity
- outcome : major morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Mittwoch, 2. April 1997
This is the short description of
the incident:
| 5 yr old child was scheduled for elective anal surgery under combined general/epidural analgesia. Lumbar puncture was performed twice (first attempt by a resident unsuccessful, loss of resistance technique was used, catheter was insreted and after test dose 7 cc 0.25% bupi was injected and continuous infusion (bupivacaine +fentanyl) started. Surgery went uneventful. Six days after surgery limb weakness was noticed and quadriparesis recognized. NMR revealed C4 ischemia. Child was breathing spontaneously. Two months after the indident the child recovered partially, she can walk but some limb weakness still remains. |
- This is the description of the management:
| Neurologist and neurosurgeon were consulted, dexamethasone given for five days, than rehabilitation |
Potential Severity : potentially disabling morbidity
- outcome : Minor morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Donnerstag, 27. März 1997
This is the short description of
the incident:
| nosocomial meningitis 17 hours after retrobulbar injection (two injection technique) staphylcocus haemoliticus |
- This is the description of the management:
| first recognize the severity of headaches+temp=39°5 (it was not an influenza as said the surgeon) second :making an intrathecal ponction for csf check third:as soon as the first results (hypoglycorachie +6000white cell/mm3 injection of a large antibiotherapy |
Potential Severity : transient damage with complete recovery
- outcome : Prolonged
hospitalisation.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Mittwoch, 19. März 1997
This is the short description of
the incident:
| Since I started working in the hospital, 5 years ago, we used fentanyl and succynilcoline of 2 different manufactureres and the flasks were of different colors, one green and the other brown. The day befor the event we received a new supply of succinylcholine from the same manufacturer of the fentanyl, "Farmacia". Both drugs are in flasks of the same size, 10 ml and the color is exactly the same, and so is the type of letters. I used the only green flask that was in the regular place without reading what was written on it. So before the induction I administerd 1 ml of succinylcholine instead of fentanyl. I noticed immediatly that the patient "froze" and stopped breathing. I ventilated her with a face mask for a few minutes till the effect of the drug ceased. When we all tryed to understand what happend the nurse who prepared the drugs told me about the new supply. There were no consequences to the patient. |
- This is the description of the management:
Potential Severity : death
- outcome : Patient
dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Dienstag, 18. März 1997
This is the short description of
the incident:
| fentanyl and ephedrine vials where placed on the same tray, 0,5 cc of ephedrine and 8 cc of bupivacaine 0,125 where given as a epidural bolus, instead of 0,5 cc of fentanyl. The two vials are identical. |
- This is the description of the management:
| wash catheter with NaCl and monitor blood pressure |
Potential Severity : transient abnormality unaware to the
patient
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Montag,
17. März 1997
This is the short description of
the incident:
| Instead of a solution containing Bupivacain 0.25% + 2ul Fentanyl/ml a solution containing Bupivacain 0.25% an 20ug/ml Fentanyl was prepared and administered epiduraly during approx. 4h at 5ml/h |
- This is the description of the management:
| Error was realized only several days after occurence |
Potential Severity : transient damage with complete recovery
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Donnerstag, 6. März 1997
This is the short description of
the incident:
| routine laparascopic cholecystectomy;developed pneumothorax during maintenance. Inserted chest drain; no longterm complications |
- This is the description of the management:
Potential Severity : transient abnormality unaware to the
patient
- outcome : Minor morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Freitag, 14. Februar 1997
This is the short description of
the incident:
| a 27 whittacre spinal needle was used, on the second attempt to puncture the subarachnoid space, the needle broke within the patient. The needle had to be evacuated by the surgeon under x-ray control. |
- This is the description of the management:
Potential Severity : transient damage with complete recovery
- outcome : Patient
dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Samstag, 25. Januar 1997
This is the short description of
the incident:
| after induction for an general anesthesia by an 13year old female child the prepared tube with cuff (nr.7,0)was too big for an nontraumatic intubation.Therefore we looked for the next smaler one.The 6,5 was present but only an uncuffed version. We decisioned to place this tube.After intubation the leckage was too big.We pluged a common gauze to reduce the leak. After rotating the head to the left side the leak was back again.We decided to order an cuffed version of the 6,5 tube and reintubated. |
- This is the description of the management:
Potential Severity : transient abnormality unaware to the
patient
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Donnerstag, 23. Januar 1997
This is the short description of
the incident:
| After the operation and extubation patient felt severe unilateral eye pain. Examination by opthalmologist did not show any abnormality. Probable abrasio corneae. After application of eye cream the next morning the patient was pain free. intubation was not so easy (three attempts necessary),maybe trauma to the cornea during this time, because afterwards the eyes were closed by tape with eye drops applicated. |
- This is the description of the management:
| see above |
Potential Severity : potentially disabling morbidity
- outcome : Patient
dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Sonntag, 19. Januar 1997
This is the short description of
the incident:
| Patient with 64 years old schedulled for emergency embolectomy of rigth leg. Past hystory of pulmonary cancer with liver metastasis. Active pulmonar tubercolosis Near 30 min. after subarachnoid block with 10 mg of 0.5% hyperbaric bupivacaíne plus 20 mcg of fentanil, the patient developed sudden loss of conscience, bradycardia and hypotension. |
- This is the description of the management:
| Atropine 0.5 mg and ephedrine 50 mg iv were administered without results. Tracheal intubation was performed after 70 mg of propofol and 50 mg of suxametonium. Heart rate raised to 110 b/min but blood pressure remained low. More ephedrine was administered and blood pressure turned to initial values ( 120/80 mm Hg). |
Potential Severity : potentially disabling morbidity
- outcome : Death.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Freitag, 17. Januar 1997
This is the short description of
the incident:
| A Physio-Flex respirator (Draeger) all of a sudden switched by itself from controlled ventilational mode into only inflation with a high gas flow. No exhalation was allowed by the machine and no high-pressure alarm occured. This resulted in a massive, accidental PEEP with a massive drop in blood pressure. This again occured during an immediate check of the machine without a patient afterwards. |
- This is the description of the management:
| Immediate switch to bag and manual ventilation. Circulatory support and exchange of the Physio Flex respirator. |
Potential Severity : death
- outcome : Outcome not
affectedby incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Mittwoch, 15. Januar 1997
This is the short description of
the incident:
| During repositioning of a child for Tonsillectomy an accidental extubation occured. The airway was still full of blood and there were two large tamponades in place. This made the re-intubation a little bit uncomfortable. |
- This is the description of the management:
| Re-intubation and suctioning of the airway. |
Potential Severity : death
- outcome : Outcome not
affectedby incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Monday,
December 09, 1996
This is the short description of
the incident:
| patient with complaint of weakness (gr.4/5) of all extremities after a fall had (by CT scan) atlanto-axial subluxation w/ posterior displacement of C2 resulting in severe central canal narrowing and cord compression,narrowed C3-4 and C4-5 neural exit foramina on the right side. HE underwent surgery for stabilization with SS sublaminar wiring at C1 and wiring of C2-3 spinous process. Standard nasotracheal intubation was done on an anesthesized patient with thiopental, nitrous oxide and halothane. Relaxant used was vecuronium.Patient was smoothly intubated and then positioned prone. Unfortunately, after positioning ETT cannot be inflated. Reintubation done with new ETT and patient was repositioned. Surgery was done but an intra-operative wake-up test revealed that patient was unable to move extremities, thus implant was removed and surgeons decided to close operative site. Postoperatively, patient remained quadriplegic. |
- This is the description of the management:
Potential Severity : potentially permanet morbidity
- outcome : Major morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Friday,
December 06, 1996
This is the short description of
the incident:
| I tried to ventilated the patient during anesthesia induction It was not posible due to the fact that the switch valve was set on ventilator mode. The respiratory circuit was not checked and valves were not checked preoperative. Transient hypoxemia was observed. |
- This is the description of the management:
| Switch ventilator valve to Bag mode. |
Potential Severity : potentially permanet morbidity
- outcome : Outcome not
affectedby incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Thursday, December 05, 1996
This is the short description of
the incident:
| ASA I patient after uneventfull parathyroidectomy under propofol anesthesia. Hypertensive up to 200 mmHg in PACU despite repeated doses of labetalol and nepresol. Painfree, oriented patients during regular controls. After 2.5h sudden stridor, swelling of operative region. During the following 4 minutes (emergency transfer to induction area) progressive loss of consciousness and complete airway obstruction with decrease of spontaneous air movements to zero, 0, NADA!!!. O2-Sat until then > 90%. |
- This is the description of the management:
| thio-succi and laryngoscopy. Complete (!) supralaryngeal softtissue obstruction (pressure from hematoma) No visibility of laryngeal structures. Opening of sutures by anesthesia personel does not evacuate hematoma (subfascial) Quick-trach technically unrealistic (anatomic situation). Thereafter (what could I do??) blind, forcefull, traumatic, "trans-tissue" induction of endotracheal tube in "laryngeal direction". Unexpectedly CO2 from ET --> thereafter controlled situation, vasopressors to support cerebral perfusion pressure until surgical decompression. Ventilation in ICU, delayed extubation, no neurological sequela, some bleeding and "sore throat". Fever for 2 days, thereafter uneventful. |
Potential Severity : death
- outcome : Minor morbidity.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Monday,
December 02, 1996
This is the short description of
the incident:
| during (30 minutes after start of procedure)laparascopic inguinal hernia repair the patient developped unrecocnised cutaneous emphysema up to the axilla. the responsible anaestetic nurse recocnised rising hypercapnia and tried to control c02 levels by means of hyperventilation for more than ten minutes duration. he did not recognise the cause of the problem, nor communicate the problem to the surgeons or the responsible MD anaesthetist. when finally being called the MD anaesthesist noticed c02 levels of more than 8 kpa, minute ventilation of 14 litres. the petient showed increasing number of preexisting ventricular extrasystoles, some of them in couplets. during auscultation of the lungs the grotesque cutaneous emphysema was noticed. |
- This is the description of the management:
| the surgeons whereadvised to stop surgery immediately. within 3 minutes c02 was in a acceptable range. the surgeons continued procedure without 02-insufllation and only when putting in the net restartet c02 insufflation with controlled pressure and without problems for the anaesthesia team to controll hypercarbia. the patient was ventilated for 30 minutes after the end of the operation. extubation was uneventful. because of ventricular extrasystolia the patient was transfered to monitorised unit. 4 hours later the emphysema was almost resorbed, arterial p02 was within normal range and the number of extrasystoles was within preoperative range. the cause of late recognition of the true cause of a severe problem was lack of knowledge of the nurse anaesthetist and poor communication with the surgeons and the responsible MD anaesthetist. |
Potential Severity : transient abnormality unaware to the
patient
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Tuesday, November 26, 1996
This is the short description of
the incident:
| 10 year old boy for a craniotomy because of a tumor. Stable iv.-anaesthesia with alfentanil, atracurium and propofol in left lateral position. Child was intubated with an uncuffed orotracheal tube size 6.0. At the end of the procedure the child was turned back to supine position. During this manoeuver the tube slightly dislodged because the fitting tape was no longer holding the tube secure (massive salivations). This resulted in an accidental extubation (only a few moments to early) with the airways not yet cleared from saliva and the patient not yet breathing sufficiently. |
- This is the description of the management:
| First attempt to re-intubate with laryngoscopy alone. Since not possible decision to use succinylcholine and succesful re-intubation. Regular emergence without problems afterwards. |
Potential Severity : potentially permanet morbidity
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sunday,
November 24, 1996
This is the short description of
the incident:
| An otherwise healthy 80 years-old male was operated for ressection of severe gangrena affecting the wole right leg, up to probably L4-L5 level. 20 minutes after induction, as I was calling the ICU for postop admittance of the patient,while in left lateral, a sudden bradychardia with head cyanosis appeared. Other noticed monitors: severe hypotension, desaturation, low ET-CO2. |
- This is the description of the management:
| Atropine 1mg, ephedrine 25 mg, epinephrine and dopamine infusions Standard CPR, 100% O2 ventilation |
Potential Severity : death
- outcome : Death.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Wednesday, November 20, 1996
This is the short description of
the incident:
| The resident was preparing an elderly patient for a spinal anaesthesia when she had to leave the patient for helping to extubate a child. In the meantime the preparations were completed by a staff anesthetist. When the resident came back, the patient was in a lateral position an everything was prepared to perform the spinal anaesthesia. After having turned the patient back the resident recognized that the patient had no iv-line...(the veins were rather bad and the line had to be done in the cubital vein) |
- This is the description of the management:
| Putting in the missing iv-line |
Potential Severity : transient abnormality unaware to the
patient
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Sunday,
November 17, 1996
This is the short description of
the incident:
| During disection through scar from 4 previous back surgeries, about 30 minutes from incision time, the pulse oximeter reading went from 97% to 50% in less than a minute with verification of reading on other hand's finger and ear pulse oximenter reading. Arterial line blood gas had pO2 50 with pCO2 49 pH was 7.33. Patient was under general anesthesia with O2 forane Sufenta on the Andrews table with hypotensive anesthesia with systolic bp 68-72 with mean of 48-50. Summation of St-T segments were 0-0.1 on Hewlett Packard ECG monitoring with 5 lead. When she did not respond with better oxygenation with elevation of blood pressure with ephedrine 15 mg., we turned the patient supine on her back just covering the wound with plastic drape. The hypoxemia resolved with ABG 3 minutes after the first pH 7.4 pO2 643 pCO2 35 CXR demonstrated normal lung fileds with the ET tube left endobronical position after we turned her. The tube was withdrawn with lungs fileds heard clearly both sides. However when we turned her again on Jackson table to continue the procedure, she started to desaturate again within 2 minutes so we placed her supine again. Next we attempted R lateral position without success. hypoxemia resumed. Finally we tried left lateral position, which she tolerated with pulse oximeter readings in 95%-97%. the surgeon closed the wound after vigorous irrigation with antibiotic solutions She had uneventful recovery. Postoperatively ECHO was negative. Pulmonary VQ Perfusion was negative. She did demonstrate some mild COPD restrictive component with her pulmonary functions studies. . |
- This is the description of the management:
| See above description Turn patient supine and increasse blood pressure which included fluids and ephedrine. When the ET tube had slipped down with patient moving in many positions repositioning and resecuring. |
Potential Severity : transient abnormality unaware to the
patient
- outcome : Prolonged
hospitalisation.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Tuesday, October 29, 1996
This is the short description of
the incident:
| after extubation still lying on the OR table immediately before being transterred to a trolley this 90kg male became agitated and pushed the waiting trolley aside and rolled of the Or table and fell to the floor. The head was supported during the fall the rest of the body slid down between the table and the trolley. The actual heigt of the fall was less than 50cm. |
- This is the description of the management:
| Check airway patency, revert benzodiazepines, check for early signs of neurologic damage, Reposition on trolley, close observation for several hours, radiologic studies as necessary |
Potential Severity : potentially disabling morbidity
- outcome : ....
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Thursday, October 17, 1996
This is the short description of
the incident:
| Patients O2 Sat.decreasing 15 minutes into the case w/o obvious reason. From 99% to 93%. Stat blood gas is: pH 7.54 pCO2 28 pO2 403 O2 49% Carboxyhemoglobin 50 % !!!!!! Baralyme exchanged for a new set. Hyperventialtion with 100 % o2, desflurane disconnected. Patient wakes up w/o probl. Severe nausea and headache, recovers uneventfully and discharged home. ( Kept for 4 hours on 100% o2 ) COHB after 4 hours down to 8%. |
- This is the description of the management:
| Desflurane disconnected. Baralyme exchanged. |
Potential Severity : transient damage with complete recovery
- outcome : Patient
dissatisfaction.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Friday,
October 11, 1996
This is the short description of
the incident:
| At extubation with a PIP of about 30-40cm H20 sudden drop of SpO2 and agitation of patient. In the chest Rx pneumothorax. After thoracocentesis no further complications. |
- This is the description of the management:
| thoracocentesis and ICU-Care |
Potential Severity : transient abnormality unaware to the
patient
- outcome : Unplanned
ICU-admission.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Saturday, October 05, 1996
This is the short description of
the incident:
| Assistant assigned to AAA not available ? sitting an examination. Two senior registrars unwilling to leave cases they were doing with other consultants. Junior resident assigned mid morning. Commited individual but still working out the basiscs. I had returned to work 2 days before following severe viral infection. Resident briefed on ventricualr akinesia, dopamine etc ready to use. Transient severe hypoternsion on induction concentrating on the ionotropes I failed to notice that when swapping syringe drivers he had not reprogrammed the correct maintence dose by a factor of 10X normal, ie patient had 20mg vecuronium over 30 mins after an induction dose of pancuronium. Pateint commence post tetanic facil TOF after 2hrs which coincided with the end of the case. Extubated and to ICU pain free and stable. This incident was minimised by the use of a syringe with no more than 20mg of vecuronium in it. |
- This is the description of the management:
| ceased vecuronium monitored with PNS checked that the resident did know what the dose was, asked him what he thought of the dose he had dialed and how long he thought it would paralyse the patient for. Supported him through his distress. |
Potential Severity : ...
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported:
Thursday, October 03, 1996
This is the short description of
the incident:
| Failure of Capnography with difficuly of obtaining new monitor for approx. 30 min because of failure of backup monitor |
- This is the description of the management:
| Ventilation according to ventilator settings as used (and noted on premedication sheet) in ICU before operation |
Potential Severity : transient damage with complete recovery
- outcome : Outcome not
affected by incident.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Monday,
September 23, 1996
This is the short description of
the incident:
| Iv valium valium placed in dorsum of the hand of a 24yr. old dehydrated patient for a colonoscopy. The nurse had a hard time starting IV. Results deep vein thrombosis all the way up patients arm to chest with peripheral nerve damage. Now resulting in RSD |
- This is the description of the management:
Potential Severity : potentially disabling morbidity
- outcome : Unplanned
hospitalisation of an out-patient.
Further details of this case upon request. Please mail to: Sven Staender(staender@ubaclu.unibas.ch)
|
reported: Wednesday, September
04, 1996
This is the short description of
the incident:
| Surgeon felt there is no pulse. Anesth chek and discovered disconnection of tubing system. Ballon pump alaram on for the last 40 minute. |
This is the description of the
management:
| CPR 100% O2. Atropin, Opening the chest ( The surgeon thought it may be another problem... |
The outcome of this incident was Death.
|
reported: Wednesday, August 21,
1996
This is the short description of
the incident:
| During reconstruction of an unstable C-6-fracture in prone position the attachement of the patient's orotracheal tube came undone due to hypersalivation and an accidental extu- bation occured. |
This is the description of the
management:
| Surgeon was asked to stop operation and help turn the patient to supine position. Adequate oxygenation was first secured by mask ventilation, then by reinsertion of oro- tracheal tube. After restoration of airway the operation was continued. |
The outcome of this incident was Outcome
not affected by incident.
|
reported: Sunday, August 18,
1996
This is the short description of
the incident:
| while inserting the hip prosthesis, I noticed that ETCO2 decreased abruptly. first thought that there had been a disconnection, but soon established that cicuit was complete. Systemic BP then fell rapidly, with VF occuring. Full Cpr carried out for over ten minutes but unsuccessful |
This is the description of the
management:
| commenced CPR ventilated with 100% O2 |
The outcome of this incident was Death.
|
reported: Sunday, August 18,
1996
This is the short description of
the incident:
| 46 female. Scheduled for CABGX2, Uneventfull induction-prebypass period, suddendly at initiation of Aortic cross clamp, critical increase in extracorporeal circuit followed by rupture of arterial line + blood spillage + discontinuation of CPB. What hapenned: The aortic cannula, which resembles a letter "L", with the short arm AWAY from heart, was placed by surgeon towards heart, at the time of Ao. cross clamp it was occluded and pump encounters resistance until perfusion line colapsed. Total circulatory arrest time of 7 min aprox. |
This is the description of the
management:
| Stop perfusion immediatly, Immediate steep trendelemburg, replacement of CPB circuit component, recanulation, deep hipothermia after reinitiation of CPB, Steroids - high dose |
The outcome of this incident was Minor
morbidity.
|
reported: Wednesday, August 07,
1996
This is the short description of
the incident:
| Patient walked into hospital, failed PCTA, to OR with CPR in progress for CABG. TEE available but not used. Patient could not be weaned from CPB. |
This is the description of the
management:
| IABP, max. inotropes. |
The outcome of this incident was Death.
|
reported: Saturday, August 03,
1996
This is the short description of
the incident:
| 26 yo female for mandibular fixation after fx. Nasal tube noted to be withdrawn approx. 3 cm from original position. Airway 90 degrees away from provider. ENT surgeons reinserted tube to presumed original position. SaO2 dec to 90% (from99%) within 3 minutes. |
This is the description of the
management:
| Surgery halted. Circuit checked. Breath sounds auscultated bilaterally Tube withdrawn while listening. |
The outcome of this incident was Outcome
not affected by incident.
|
reported: Sunday, July 28, 1996
This is the short description of
the incident:
| 10 fold overdose of pancuronium |
This is the description of the
management:
| waiting, the patient came intubatet from icu and went back to icu |
The outcome of this incident was Outcome
not affected by incident.
|
reported: Monday, July 22, 1996
This is the short description of
the incident:
| Patient developped a severe bronchospasm just after intubation. At first, it was difficult to say whether the endotracheal tube was in the trachea, because auscultation was silent... |
This is the description of the
management:
| Patient was hand ventilated and it was now possible to hear very faint breath sounds. As the sounds were louder on the right side, the tube was pulled back 2 cm. Anesthesia was susequently deepened with enflurane and a bronchodilator administrated. |
The outcome of this incident was Outcome
not affected by incident.
|
reported: Friday, July 19, 1996
This is the short description of
the incident:
| Patient for an urologic procedure, colocation of a catheter, duble/J. with out any relevant history. Fasted for more than 6hrs. 40 minutes after the induction the patient presents a liquid vomitus (brow-redish) more or less 150 ml. He was ventilated with a LMA, after the vomitus we change to a OT, we start with antibiotics and a bronchial lavage. Then he developed a Aspiration Neumonitis and he was ventilated for 6 days with SpO2 <90% PEEP 15 on the 8 day he was extubated and he goes home OK |
This is the description of the
management:
| I changed the LMA for a OT, I srt antibiotic, steroids, call the Neumology team, for a bronchial lavage, aspirate the stomach and foud 700cc of liquid (brown-redish). We took him to the PACU with out OT with a oxigen face masck. Rx reveal an incipient Broncoaspiration Sx. 3 hours later we intubate again and ventilate for 6 days. |
The outcome of this incident was Patient
dissatisfaction.
|
reported: Saturday, July 13,
1996
This is the short description of
the incident:
| Patient under spinal anesthesia. Surgeon requested cefazolin be administered. New anesthesia resident didn't read the label and drew up vecuronium thinking he was drawing up cefazolin. Drug administered. Patient became paralyzed while conscious. Patient ventilated, didn't become hypoxemic. Took 8 minutes to realize what had happened. At that point patient was given nitrous and propofol and intubated. Subsequently, NMB reversed. Patient did well. |
This is the description of the
management:
| see above |
The outcome of this incident was Unplanned
hospitalisation of an out-patient.
|
reported: Friday, July 12, 1996
This is the short description of
the incident:
| Elective patient for repair of iliac-aneurysm (spurium; after orthopedic surgery in the hip with osteosynthetic material). No problems intra-OP. During emergence sudden severe drop in BP, req. cardiopulmonary resuscitation. Reason: sudden severe blood-loss from the surgical field after manipulation of the former operated hip. (lesion to the vessel ?) |
This is the description of the
management:
| CPR, volume resusc., emergent re-OP. |
The outcome of this incident was Unplanned
ICU-admission.
|
reported: Friday, July 12, 1996
This is the short description of
the incident:
| Patient with severe mitral regurgitation and aortic stenosis scheduled for valve replacement of both valves. Monitoring with SG pulmonary artery catheter. After cannulation of the right atrium for cardio-pulmonary bypass it was no longer possible to manipulate the SG-catheter, because the upper canula of the cpb-pump was so tight fitted in the right atrium. Consequently the catheter remained in this position for the whole bypass-period. After restitution of a spontaneous circulation suddenly blood in the endotracheal tube. The chest X-ray after the operation showed a small, light shadow at the tip of the catheter, suggesting a pseudo-aneurysm of the pulmonary artery. |
This is the description of the
management:
| Since the bleeding stoped spontaneously, an pulmonary angiogram was performed 7 days later, showing no aneurysm. |
The outcome of this incident was Prolonged
hospitalisation.
|
reported: Thursday, July 11,
1996
This is the short description of
the incident:
| bloodsample taken from a central venous cath. (Cavafix),where at that time norepinephrin was given. As a result blood pressure falled and a certain amount of the taken blood given back (Intention: heighten a little BP with NA as before), directly afterwards dangerous rise in BP to 280 ! mmHg. Realising at once and reaction at once with totally 500 y Nitroglycerin. The EEG showed no reaction and the patient had no residuae fortunately. |
The outcome of this incident was Outcome
not affected by incident.
|
reported: Wednesday, July 10,
1996
This is the short description of
the incident:
| Elective patient for kidney transplantation. During reperfusion of the transplant-kidney suddenly acute bradycardia increasing to an asystoly. |
For management / resuscitation, the
following drugs have been used: ephedrin .atropin.100%
oxygen.
The outcome of this incident was Outcome
not affected by incident.
|
reported: Wednesday, July 03,
1996
This is the short description of
the incident:
| Patient underwent a TURP under spinal anesthesia. After he was back in his room, he tried to stand up before having fully recovered from the effects of the spinal anesthetic. He subsequently fell to the ground which resulted in a femoral neck fracture. |
Short description of the management of the presented incident: Patient
was back in the theater for total hip replacement the next
morning..
The outcome of this incident was Prolonged
hospitalisation.
|
reported: Monday, June 24, 1996
This is the short description of
the incident:
| Diagnostic workup of the eyes of a child. Inhalational anesthesia with the child spontaneously breathing. Due to new capnographic monitoring devices accidentally use of a too small in size dapater for in-line capnography. This device (intended for use in neonates) resulted in a critical narrowing of the tubings with a resulting hypercapnia. |
Short description of the management of the presented incident: Change
of the adapter to the correct size. Slow re-correction of the
etCO2..
The outcome of this incident was Outcome
not affected by incident.
|
reported: Sunday, June 09, 1996
This is the short description of
the incident:
| delayed respiratory depresion due to a ten times higher dose of intrathecal morphin (1.5 mg.). Also the patient was not put in protocol for it opioids obvervation. |
Short description of the management of the presented incident: Patient
was blue at the time of diagnosis with respiratory rate less than
6 per minute, so: 1 Verval and tactil stimulation 2 oxigen 3
naloxon bolus plus infusion 4 transfer to recovery room.
The outcome of this incident was Outcome
not affected by incident.
|
reported: Tuesday, June 04, 1996
This is the short description of
the incident:
| Patient scheduled for hip surgery. Due to an existing study-protocol on spinal anaesthesia, the amount of Bupivacain was given by the randomization. This resulted in the application of 20 mg of isobaric Bupivacain 0.5% to patient beeing 160 cm tall (ca. 5 feet). The resultant level of block was C5. The patient had no discomfort with this high level of block but pressors were needed to control blood pressure (Phenylephrine). |
This is the management:
| Carefully evaluating the possible further extension of the block; Blood pressure control with pressors. |
- outcome : Outcome not affected by incident.
|
reported: Saturday, May 18, 1996
This is the short description of
the incident:
| 42 year old G4 after 3 Cesarean Section, 37 weeks gestation. For emergency Cesarean Section due to onset of labor. No indication of difficult intubation. After Ketamine-Thiopentone-Succinylcholine on laryngoscopy - full visualization of vocal cords but impossibility of passing endotracheal tube down to No. 6. Laryngeal mask No.4 inserted and ventilation and oxygenation secured. Operation completed without incident. |
This is the management:
- outcome : Outcome not affected by incident.
|
reported: Saturday, May 18, 1996
This is the short description of
the incident:
| This patient had been diagnosed as brain dead two days earlier. (Hypoxic encephalopathy after benzodiazepine and alcohol intoxication). She was transfered to our hospi- tal for organ donations. She was ventilated and required only dopamin to support the blood pressure. As she came with the helicopter, we had to change the dopa- min driving pump. Later, as a coronarography was carried out (preoperative exam prior to donation), the driving pump broke down (appa- rently because the syringe the patient had come with did not fit our driving pump). As a result, the blood pressure fell to about 70 (systolic). The resident asked the anesthesia nurse to go back to the OR to get a new dopamin syringe, intending to support the blood pressure with incremental doses of phenylephrine in the meantime. The nurse was so concerned with the blood pressure, she injected manually 2 ml of dopamin from the syringe and then only told the anesthesia resident. Extreme hypertension and tachycardia ensured... |
This is the management:
| First of all an attempt was made to measure the blood pres- sure non invasively. The blood pressure was impossible to measure (apparently because it was so high). In the meantime, the cardiologist spontaneously decided to measure the blood pressure invasively through the side-arm of the angiography catheter. This was done in about one minute... Systolic blood pressure was about 220 and, as esmolol was not available, nitroglycerine was used. A new dopamin syrin- gue was eventually connected to the driving pump... |
- outcome : Outcome not
affected by incident.
|
reported: Wednesday, May 15,
1996
This is the short description of
the incident:
| After admnistration of propofol it was impossible to see the laeynx of the patient with the bronchoscope. After coughing of the patient a bleeding in the pharynx occured. So an intubation with the broncoscope was unable. The anethetist tried to ventilate by an face-mask. It failed. So he tried to ventilate with an laryngeal mask. That was sucessful. He positioned an endotracheal tube through the laryngeal mask. Then the operation took place. After the operation he extubated the patient, who was not enough conscious. In the recovery-room an tracheotomy as emergency-OP was done, because the patient was respiratory insufficient with an pCO2 of more than 100mmHg! After two days the patient could ventilate through the normal airway! |
This is the management:
| see above |
- outcome : Unplanned ICU-admission.
|
reported: Saturday, May 11, 1996
This is the short description of
the incident:
| Accidental oesophageal intubation with decrease in oxygen saturation, bradycardia |
This is the management:
| oxygenation with mask,reintubation |
- outcome : Major morbidity.
|
reported: Monday, May 06, 1996
This is the short description of
the incident:
| allergic reaction after administration of thiopental. the patient became bronchospastic and a hypotension. in her history the pat. had a penicillin-allergy |
This is the management:
| after aminophylin and cortison and topic medicaments and volume |
- outcome : Outcome not affected by incident.
|
reported: Friday, May 03, 1996
This is the short description of
the incident:
| Oxygen pipelines had to be disconnected and reconnected on the opposite wall. The patient was thus shortly ventilated with an Ambu bag. After the pipelines were reconnected on the wall, the patient was hooked again to the respirator. One minute later, the anesthesiologist consultant noticed , although the respirator was turned on, that there was no oxy- gen flowing... |
This is the management:
| Turning the oxygen flowmeter on. |
- outcome : Outcome not affected by incident.
|
reported: Thursday, May 02, 1996
This is the short description of
the incident:
| refill of vaporizer during cardiac surgery. vaporizer not turned on after refill. hypertension before/during sternotomy. |
This is the management:
| vaporizer turned on and additional benzodiazepine iv |
- outcome : Outcome not affected by incident.
|
reported: Thursday, May 02, 1996
This is the short description of
the incident:
| Patient not ventilated during insertion of central venous line. Failure not discovered until the end of cannulation. No adverse outcome.R |
This is the management:
| Turned the ventilator on! |
- outcome : Outcome not
affected by incident.
|
reported: Wednesday, May 01,
1996
This is the short description of
the incident:
| After the delivery of the patient by the REGA-team (swiss helicopter rescue service), I recognized an yellow ear-foam in both ears. Therefore the initial examination was hardly possible; first we thougt in an intoxication, serious high cerebral-pressure or unknown motherlanguage. Nice to know that motodrivers often use an ear-foam to protect thereselves from noise... |
This is the management:
- outcome : Outcome not
affected by incident.
|
reported: Tuesday, April 30,
1996
This is the short description of
the incident:
| Patient after aortic valve redo from the same day. Initially stable in the ICU; depending on pacemaker post-operatively. Then in the ICU steadily increasind bleeding, leading to an emergent re-operation. Pat. transfered to theater with all monitoring devices, external pacemaker, three thoracic drainages, foley catheter, ETT etc. Then in the OR after transfer to the theater-table sudden complete cardaic arrest because of a disconnection of the external pacemaker-wires. |
This is the management:
| Instantaneous CPR and re-connection of the external pacemaker electrodes. This took about three minutes. |
- outcome : Outcome not
affected by incident.
|
reported: Thursday, April 25,
1996
This is the short description of
the incident:
| Patient with laryngeal carcinoma was scheduled for bilateral neck dissection. Initially he was treated with radiotherapy and the laryngoscopy showed a changed epiglottis and identification of larynx entry was not easy but reached by the first attempt. Anesthesia and the operation were uneventful. Biopsias from larynx were taken. Emergency from anesthesia was not a problem. Patient demonstrated little inspiratory stridor but was breathing calm without retractions. In the recovery room he went well for about two hours. At one he started developping more inspiratory stridor and was feeling uncomfortable. |
- Short description of the management of incident: Steroids and adrenalin for Inhalation were given and the surgeon was phoned.In about ten minutes the situation turned to a real emergency. Patient was completely uncooperativ but not hypoxaemic. A tracheotomia was necessary. Mask ventilation and conventional intubation attempt seemed not to be a good option. Two things leaded probably to this emergency. First : edema after the larynx has been biopsed. Second: bleeding of the bilaterally performed neck dissection like a "Müller" manoeuvre. .
- outcome : Unplanned ICU-admission.
|
reported: Wednesday, April 24,
1996
This is the short description of
the incident:
| Induction planned with Thiopentone, Fentanyl, Atracurium. The team did not prepare the drugs by themselfs. Instead, already prepared drugs are commonly used by other teams, as long as they are to be considered sterile. Due to this fact, a 20 cc syringe with Cefamandol was accidentally held for beeing 20 cc of Thiopentone. Both syringes were correctly labeled, but the label were covered. Additionally, since this mistake happened during preparation of the drugs, two syringes were around and the antibiotik-syringe was not there, further leaving the team in this wrong believe. Induction was tried with this wrong syringe. The mistake was discovered by the nurse after the patient did not fall asleep. |
- Short description of the management of incident: Injection of additional Thiopentone. Now the right one... .
- outcome : Outcome not
affected by incident.
|
reported: Wednesday, April 24,
1996
This is the short description of
the incident:
| Induction for a minor urologic procedure with Etomidate-Lipuro (0.3 mg/kg), Fentanyl (3 mcg/kg). Patient became unconscious. Relaxation with Atracurium after check of possibility to ventilate by mask. After 3 minutes slowly increasing in heart rate while still manually bag and mask ventilation, waiting for the muscle relaxant to work. Then moving and attempt to open the eyes. We then calmened him and injected Thiopentone to send him back to sleep again. |
- Short description of the management of incident: Thiopentone for a deeper level of anesthesia and Midazolam for at least some antegrade amnesia. .
- outcome : Outcome not affected by incident.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| During an operation for an Aortic disection, the surgeon started complaining repeatedly, blaming the operational problems on the patient's nationality (This must be one of those twisted German aortas- they are all so crooked!). He said it so that it was not clear if he meant "Germans" or "German aortas" were twisted. Two members of the team were German. |
- Short description of the management of incident: Nothing, but the surgeon should have been told that there were 2 Germans in the OR, and that the possibility of a conscious patient is always real. .
- outcome : Outcome not
affected by incident.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| Interscalene block failed. Decision to perform surgery under GA. Resident was unable to intubate (2 attempts), anesthetic nurse was also unable to intubate (2 attempts); mask ventilation possible, but difficult; staff anesthetist could not intubate (3 attempts); fiberoptic intubation failed because larynx could not be seen; airway maintained by larygeal mask; a second anesthetic nurse entered and asked whether he could try to intubate, staff responsible for case agreed; successful intubation by the anesthetic nurse so that surgery could be performed. Because of lateral positioning, surgery could not have been performed without a secure airway. |
- Short description of the management of incident: see report .
- outcome : Outcome not
affected by incident.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| After an uneventful spinal anesthesia the patient was transferred to the recovery room on a trolley. There he was transferred to a hospital bed and dropped to the ground during the transfer to bed. |
- Short description of the management of incident: X-ray for exclusion of possible fractures .
- outcome : Outcome not affected by incident.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| atracurium labeled as ephedrine. Error in labeling discovered before any drug (atracurium or ephedrine) injection/administration |
- Short description of the management of incident: All "ephedrine seringes" emptied and atracurium and ephedrine newly prepared with correct labels .
- outcome : Outcome not
affected by incident.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| A wet tap occured in a patient scheduled for a minor vascular procedure because of a faulty technique. During advancing the Tuohy needle, the left hand of the provider was not stabilized on the back of the patient and a sudden loss of resistance in the ligamentum flavum lead to a uncontrolled advancement of the needle into the subarachnoid space. |
- Short description of the management of incident: Placement of another epidural one level above. Three days later a blood patch was necessary. .
- outcome : Prolongation of
the hospitalisation.
|
reported: Tuesday, April 23,
1996
This is the short description of
the incident:
| For a transurethal manipulation of a kidney-stone a patient has had a lumbar epidural katheter placed without problems (loss of resistance technique). No fluid was beeing aspirated by a firm aspiration through the catheter in place. Test dose consisted of bupivacain 0.5%, 3ml with epinephrine 1:200 000. This resulted in a slight increase in heart rate from 70/min to 82/min. No signs of systemic tox. at this moment. Since this was not completely sure, a second test-dose was given, now beeing plaine lidocaine 2% 5 ml via epidural catheter. Now the patient reported signs of systemic toxicity. |
- Short description of the management of incident: Removal of the catheter and placement of a new epidural catheter one level above. Midazolam to prevent further complications of the systemic local anesthetic drug. .
- outcome : Outcome not
affected by incident.
|
reported: Monday, April 22, 1996
This is the short description of
the incident:
| Patient for mitral replacement because of severe mitral regurgitation. Monitoring with Swan Ganz PA-catheter. At the end of cardiopulmonary bypass suddenly blood in the endotracheal tube. Because of normal hemodynamics no evidence for left heart failure. No major hemorrhage. Spontaneus resolving of bleeding. Chest X-ray after the procedure showed a patchy sign in the right middle segment of the lung. A post-operative angiogram confirmed the hypothesis of a lesion of the pulmonary artery tree. The SG-catheter had been unblocked situated in the wedge-position during bypass. |
- Short description of the management of incident: Since the bleeding stopped by itself, no further action was required. .
- outcome : Prolongation of
the hospitalisation.
|
reported: Sunday, April 21, 1996
This is the short description of
the incident:
| 17 h after uncomplicated EA for histerectomy patient become apneic, asistolic. For postop analgesia she gave fentanyl 0.15 mg during the surgery and morphine 0.3 mg after operation (all drugs in the epidural space). Recovery without incident. 11 h after morphine injection ward nurse injected 15 mg of Dipidolor (Pirithramide). 6 h after Dipidolor injection the patient become apneic. |
- Short description of the management of incident: Endotracheal intubation, lungs ventilation with 100% oxygen, adrenaline, i/v fluids .
- outcome : Major morbidity.
|
reported: Sunday, April 21, 1996
This is the short description of
the incident:
| Just coming off cardiopulmonary bypass and intending to sue small dose of adrenaline. However, resident has not reaslized that syringe line had not been flushed. Connected and about to set rate when I realized had not been flused. Pointed out about 1ml air in IV line from syringe pump. Resident disconnected from patient, flushed with syrigne driveer and then re-connected. No harm. some delay in coming off bypass (about 1minute). Patient did well. |
- Short description of the management of incident: as above - cleared out air. .
- outcome : Outcome not affected by incident.
|
reported: Friday, April 19, 1996
This is the short description of
the incident:
| 20mg of pitocin (2mL) were injected instead of 100 mg succinyl choline (2mL) intended for muscle relaxation to facilitate endotracheal intubation. |
- Short description of the management of incident: succinyl choline was given for relaxation and the patient was intubated. Halothane 2% was given in the inspiratory gas mixture to cause uterine muscle relaxation. .
- outcome : Outcome not affected by incident.
|
reported: Wednesday, April 17,
1996
This is the short description of
the incident:
| inadvertant inflation of tourniquet cuff for hours, neuropathology post-op |
- Short description of the management of incident: Tourn cuff removed, leg observed .
- outcome : Patient dissatisfaction.
|
reported: Wednesday, April 17,
1996
This is the short description of
the incident:
| Surgery: Aortic valve replacement/CABG x 1 with a vein graft to RCA. Signif. air noted in LV chamber on TEE, prior to coming off bypass. Surgeon thought he had removed enough air, anesthesiologist suggested that there was more air that should be removed. Surgeon thought that enough air had been removed. Came off bypass with the table in trendelenberg position. ST segments started rising in Lead 2 and heart started to dilate. Patient placed back on CPB. LV and RCA vein graft vented to remove air. Patient then successfully weaned from CPB Surgeon is not an advocate of the use of TEE except in MVR surgery and a very limited number of patients. TEE was useful in quantifying the amount of air in the LV. |
- Short description of the management of incident: Surgeon vented the LV and graft .
- outcome : Outcome not affected by incident.
|
reported: Wednesday, April 17,
1996
This is the short description of
the incident:
| A healthy, adequately premedicated child (midazolam) has had a corrective surgery for strabismus. After an uneventful anesthesia with propofol and alfentanil the patient recovered complete upset, agressive, screaming. Analgesics did not help (paracetamol and nalbuphine). The patient cleared up after a single dose of physiostigmine. |
- Short description of the management of incident: Checking appr. analgesia; Physiostigmine because of typical signs of centr. anticholinergic syndrome. .
- outcome : Outcome not affected by incident.
|
reported: Wednesday, April 17,
1996
This is the short description of
the incident:
| Known Pneumothorax (caused by Trauma) already dealt with by chest tube placement, became a tension pneumothorax intraoperatively, due to sudden insufficiant drainage through the chest tube. |
- Short description of the management of incident: Aneasthesia Consultant realized the problem was a tension pneumothorax, informed the surgeon, who confirmed the diagnosis and inserted another chest tube (same side). .
- outcome : Outcome not
affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| After a nasopharyngeal tamponade because of massive bleeding the patient emerged uneventfully at the beginning. He was perfectly breathing still intubated. After he swallowed and opened his eyes the endotracheal tube was removed after suctioning his mouth and pharynx. In the subsequent seconds we realized, that we could not maintain an open airway with the face-mask. The airway was completely closed. All maneuvers failed and we were forced to re-intubate him because of a severe drop in saturation. During re-intubation we saw, that the nasopharyngeal tamponade was so hughe, that it pressed down the soft palate, leading to a complete obstruction of the upper airway. Re-intubation was uneventful. |
- Short description of the management of incident: Emergency re-intubation and having the surgeon adjust the size of the tamponade. .
- outcome : Outcome not
affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| Breathing bag was accidentaly connected to the expiratory limb of the circle system after transferring the patient from the induction room to the operating theatre |
- Short description of the management of incident: correct connection of the breathing bag .
- outcome : Outcome not affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| Patient was scheduled for an arterio-venous malformation embolisation. The radiologist said he was giving the patient "nitro" to loosen up spasm of an intracerebral artery. When asked about the dose he said "one milliliter". Shortly therafter, the patient complained of nausea. The very attentive anesthetic nurse immediately understood what had happened and prepared ephedrine. The resident checked the pulse and blood pressure which was 60 (systolic). He then injected twice 20 mg ephedrin. In the meantime, the nurse had already prepared a syringue of phenylephrine. With 100 mcg pf phenylephrine, the blood pressure was brought back to 115 (systolic). It later turned out the radiologist had injected 100 mcg of nitoglycerine... |
- Short description of the management of incident: IV ephedrine + phenylephrine .
- outcome : Outcome not affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| A median approach at L3-4 was made , the patient being in the sitting position. Loss of resistance was frank. There was no CSF flowing out of the 18 G Tuohy needle. The catheter was eventually introduced through the needle. I immediately noticed it was unusually easy to adavnce the catheter. The fear of having punctured the Dura was confirmed when aspiration test was preformed and CSF could easily be aspirated on the tip of the catheter. |
- Short description of the management of incident: We switched to continuous spinal anesthesia. Instead of continuous peridural analgesia, we chose to inject 0.3 mg morphin intrathecally at the end of the case. .
- outcome : Outcome not affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| Instead of giving heparine at the start of extracorporeal circulation protamin has been given. Both ampoules lie close to each other in the tray. |
- Short description of the management of incident: Under control of the coagulation parameters, heparin was given.
- outcome : Outcome not affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| During transport to hospital of a patient who shot himself in the head in a suizidal attempt, the endotracheal tube became dislodged into the oesophagus. This was neither recognized nor corrected during transport or in the emergency room. |
- Short description of the management of incident: As soon as the patient deteriorated, the team decided, not to prolong the resuscitation because of the suizidal attempt. .
- outcome : Death.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| After the end of a MRI in monitored anesthesia care, the team realized, that the bag and mask system were completely missing |
- Short description of the management of incident: no management, despite organization of aditional material .
- outcome : Outcome not affected by incident.
|
reported: Friday, April 12, 1996
This is the short description of
the incident:
| Instead of 20cc promit (dextran allergy prophylaxis) 20cc of bupivacaine 0.5% was given straight iv by the anesthetic nurse (both ampoules look the same...) after a few minutes, the resident saw the empty bupivacaine ampoule (intended for the later start of the combined anesthesia) and realized, what has happened ... |
- Short description of the management of incident: close observation ( cv status, arrhythmia....), prepared antiarrhythmic drugs, wait ... .
- outcome : Outcome not affected by incident.
|
reported: Thursday, April 11,
1996
This is the short description of
the incident:
| Hypotension with short loss of consciounes, concom. epileptic seizure. |
- Short description of the management of incident: Voulme replacement, trendelenburg positioning .
- outcome : Outcome not affected by incident.
|
reported: Thursday, April 11,
1996
This is the short description of
the incident:
| Instead of emerging with a high-flow combination of air in oxygen accidentally N2O in oxygen was turned on. Since the oxygen analyzer was not in use, a mixture of 50% N2O in oxygen was given, sufficient to leave the patient in anesthesia. |
- Short description of the management of incident: After reversing narcotics with no major effect on vigilance of the patient, the problem was identified and the patient emerged without problems, after turning off the N2O .
- outcome : Outcome not
affected by incident.
|