The March 2014 issue of the NEWSLETTER contained a case report about a medication error regarding an overdose of insulin (“Case 2014-03: In the Eyes of the Beholder”). This prompted me to share the following: When I was a first-year anesthesiology resident at SUNY Syracuse, I made a significant medication error. Fortunately, I recognized the mistake. As a result, an intervention ensued such that the patient came to no harm. The case was an ORIF of a compound fractured femur, under general anesthesia. It occurred in the middle of the night when I was tired. At the end of the uneventful surgical part of the procedure, I administered what I thought was a mixture of neostigmine and glycopyrrolate to reverse the NMB. Unfortunately, and to my horror, I discovered that I had drawn up a mixture of ephedrine and glycopyrrolate. Fortunately, the patient was young and otherwise healthy, so the...
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Letter to the Editor|
July 2014
Medication Error Lesson Lasts an Entire Career
John DesMarteau, M.D.
John DesMarteau, M.D.
Washington, D.C.
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ASA Newsletter July 2014, Vol. 78, 62.
Citation
John DesMarteau; Medication Error Lesson Lasts an Entire Career. ASA Newsletter 2014; 78:62
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