Study: IV labeling may cause anesthesia errors

Hard-to-read IV bags may be enough to cause major anesthesia errors, study found.

One of the major risks associated with surgery is an anesthesia error. Since it takes many years of training to become an anesthesiologist or nurse anesthetist, you may assume that when this type of error occurs, it is due to a technical oversight that is not immediately apparent to the layperson. However, a recent study found that this is not always the case. It concluded that something as simple as an inability to read an IV label could be a routine cause of serious anesthesia errors.

Details of study

The study was conducted at the VA Pittsburgh Healthcare System and published in the Journal of Patient Safety. During the study, 96 anesthesiology students were prompted to perform a simulated surgical procedure. The procedure itself was based on a real life occurrence where an IV bag of lidocaine was almost used instead of a bag of hetastarch. Luckily, the mistake was caught, as it would have killed the patient.

During the study, the students performed two rounds of simulated surgical procedures. For each round, an anesthesia cart that had IV bags of lidocaine and hetastarch improperly mixed within the same drawer was used. During the first round, the cart was stocked with IV bags with labeling used by virtually all hospitals. Such labeling is often printed on a clear background over a clear bag. For the second round, the cart was stocked with IV bags with enhanced labeling printed on opaque white paper with a dark background, to make the writing stand out.

Interestingly, the simple change in IV label design had a profound effect. During the round where standard labeling was used, 60 percent of the students used the wrong drug, which would have been a fatal error in real life. However, when the enhanced labeling was used during the second round, the students were 2.61 times more likely to choose the correct IV bag from the cart.

Due to the considerable difference that the enhanced labels made, the hospital where the study was conducted decided to change the IV labels used in all its surgical procedures. The study’s authors hope that the publicity generated by the published study will convince other hospitals to do likewise.

What to do if injured

In real life, if you or a loved one is the victim of an anesthesia error, there is often no chance to correct the mistake, as such a mistake can cause brain damage, a heart attack, stroke or coma. Although the hospital staff may be responsible for the error, they often are slow or reluctant to admit it or point out a colleague’s mistake. Unfortunately, it is often only after an investigation during a medical malpractice lawsuit does the error come to light.

If you suspect the negligence of a medical provider during a surgical procedure, you may be entitled to recover compensation for your medical bills, pain and suffering, loss of income and other losses under Michigan law. The experienced medical malpractice attorneys at McKeen & Associates, P.C. can work with anesthesia experts to reveal the existence of the error and hold the responsible parties accountable under the law.