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Started By
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re: Woman says mother-in-law paralyzed after receiving potassium during surgery
Posted on 8/19/26 at 3:04 pm to Funky Tide 8
Posted on 8/19/26 at 3:04 pm to Funky Tide 8
We do hip hemiarthroplastys under spinal if the patient is too fragile to receive medication for intubation. Femoral nails too. Its not uncommon, just depends on the patient’s situation
0
Posted on 8/19/26 at 3:14 pm to RicFlairWhoooooo
quote:
At our hospital this local anesthetic is taken from its original vial and placed into small syringes by the pharmacist/pharmacist tech so that an entire vial is not wasted on each patient.
quote:
In a busy hospital with a flip room, not out of reason that 4 patients could have gotten the spinals with the wrong medication before the first one reached the recovery room and they realized there was an issue.
How manh doses would be in the original vial, 4? Four patients could have gotten the doses of the original, mistaken vial, and the pharmacist/tech moved to a new, correct vial. Is that possible?
Meaning the pharmacy used up the mistsken vial and moved on to a fresh one when prepping for tbe day's surgeries without noticing the mistake?
Posted on 8/19/26 at 3:15 pm to TechDawg2007
I can’t count the number of these I’ve been a part of and potassium being in the mix blows my mind. Typically a spinal tray is opened that contains all anesthetics, needle and syringe, but morphine is drawn up separately. Anesthesia does have potassium ampules available in surgery to mix a drip if needed. I guess those ampules could have been put into same spot as morphine, then not verified by person who checked it out. Awful situation
Posted on 8/19/26 at 3:18 pm to LegendInMyMind
10-15 doses from one vial. Which is why they do it. Treat 10 patients with one vial instead of 10 patients with 10 vials where a large majority is thrown away.
By the time the first patient or two reached recovery room and they realized they were not moving lower extremities like they should have been, the 3rd and fourth patient had already receive their spinals
By the time the first patient or two reached recovery room and they realized they were not moving lower extremities like they should have been, the 3rd and fourth patient had already receive their spinals
This post was edited on 8/19/26 at 3:22 pm
Posted on 8/19/26 at 3:20 pm to RicFlairWhoooooo
So, they likely caught it before they worked through that original vial? At least there's that. That all sound plausible.
Posted on 8/19/26 at 3:22 pm to RicFlairWhoooooo
quote:
most places have moved to Mepiviciane, which is shorter acting local anesthetic so patients are able to get up sooner after surgery and start walking
This is SOP at MOI and I think just about every facility we service in the KC/STL. & Springfield metro areas.
Posted on 8/19/26 at 3:29 pm to TechDawg2007
I thought it was worse than this. A nurse made a video saying the hospital had 9 sentinel events in one day. The daughter in law commented there about her family member being one of them. I hope that nurse had it wrong. 4 is tragic anyway but to have 9 before discovering it is unbelievable.
Posted on 8/19/26 at 3:31 pm to RicFlairWhoooooo
quote:
By the time the first patient or two reached recovery room and they realized they were not moving lower extremities like they should have been, the 3rd and fourth patient had already receive their spinals
That would make a lot of sense as to how they got to 4 before realizing it. So awful.
Posted on 8/19/26 at 3:37 pm to Scruffy
quote:
likelihood of this happening to you is exceptionally low.
Yeah, I was joking. I text him and told him I would eat a banana ahead of time if he promised not to paralyze me thru anesthesia, lol
Posted on 8/19/26 at 3:41 pm to America250
quote:
This hospital should be forced to close its doors after paralyzing 4 patients.
It's not that easy. It's a very well-regarded hospital that treats thousands of patients and has high quality scores. They've got a great history.
They said they've identified what happened, just haven't released it yet. I don't think closing this hospital is the right move if this is proven to be an isolated fluke incident.
They also have like 80,000 ER visits annually. Can't just remove that from the community.
Posted on 8/19/26 at 3:54 pm to CatfishJohn
It's 4 paralysis cases. Corrections/Proper Protocols should have been made after the 1st case, so those 3 other cases would have been prevented
Posted on 8/19/26 at 3:57 pm to America250
quote:
It's 4 paralysis cases. Corrections/Proper Protocols should have been made after the 1st case, so those 3 other cases would have been prevented
There was a good explanation of how this could happen in this thread.
Same vial, separate doses prepared by hospital pharmacy, patients were treated with same incorrect medicine before they knew there was an issue.
Posted on 8/19/26 at 4:27 pm to CatfishJohn
Those 4 surgeries weren't on the same day. Why wasn't the hospital using single dose vials for each surgical case, instead of 1 large vial used multiple times on multiple cases. Should have been one single dose vial with patient's name and date of birth on the label.
Ive assisted with surgery cases and the anesthesiologist always received meds from pharmacy with patient identifying information on it. They ask patient their name and DOB if conscious, or matched their name on their armband if unconscious.
That's protocol on every operation.
Ive assisted with surgery cases and the anesthesiologist always received meds from pharmacy with patient identifying information on it. They ask patient their name and DOB if conscious, or matched their name on their armband if unconscious.
That's protocol on every operation.
Posted on 8/19/26 at 7:54 pm to America250
Hospital pharmacist here— we do
compound some epidurals in the IV room. Every single med made in the IV room is scanned &
pics of each ingredient, the amount drawn up &the final product are taken during the process. We use the Dose Edge system. IV techs prepare the med in the sterile room. A pharmacist checks each picture that is of every step in making it. Our system will not let you proceed if the barcode will not scan. This tragedy is very hard to understand right now. Most pharmacies use the barcode scan technology today. It is an extra safety check.
compound some epidurals in the IV room. Every single med made in the IV room is scanned &
pics of each ingredient, the amount drawn up &the final product are taken during the process. We use the Dose Edge system. IV techs prepare the med in the sterile room. A pharmacist checks each picture that is of every step in making it. Our system will not let you proceed if the barcode will not scan. This tragedy is very hard to understand right now. Most pharmacies use the barcode scan technology today. It is an extra safety check.
Posted on 8/19/26 at 8:20 pm to TechDawg2007
We’re going to see more and more of this thanks to leftist policies of lowering the standards.
Posted on 8/19/26 at 8:26 pm to America250
They use 1 large one and draw off of it because it’s CHEAPER!!!
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