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Abstract
Despite its simplicity, accidents resulting from the administration of local anesthetic
agents and parenteral fluids have undoubtedly been more numerous than one would be
led to believe from the few isolated cases which have been reported. While this may
be construed as indicative of the infrequency of such accidents, nevertheless, it
is more likely due to a failure to publish them. Physicians are always eager to report
successes, but are equally reluctant to record failure or mistakes.
We believe that more accidents and reactions occur as the result of injection of the
wrong solution, or one improperly prepared, than those due to sensitivity to the agent.
When a physician has had the misfortoune of administering the wrong solution, and
a severe reaction has ensued, he is of the opinion, and perhaps righly so, that he
would be blamd for the accident, and so it has seemed to him that no good purpose
would be served by reporting it. Thereby, the custom has grown up of not recording
these accidents, although a service might have been rendered by repeatedly calling
to the attention of the medical profession the possibility of mistakes, and emphasizing
the need for safeguards in an effort to prevent them. It was with this idea in mind
that the present study was undertaken, since we were unable to find reference in the
medical literature to any work on this problem. Discussion may stimulate further investigation
which may lead to better prophylaxis.
The migration of student and graduate nurses through the various operating rooms has
enhanced the possibility of the surgeon's being given a syringe containing the wrong
colorless solution. Substitution accidents may occur in several ways. The error may
have been made in the pharmacy where either the wrong or an improper solution was
made, or the final package was improperly or incompletely, labeled and identified.
Of more frequent occurrence, in our opinion, is the error made by the nurse, the house
officer, or the surgeon himself, who having several colorless solutions, such as alcohol,
ether, procaine, saline, etc., on the instrument tray, may draw into the syringe the
wrong solution for injection. While this error may seldom occur, when it does the
result may be a
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References
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Article info
Footnotes
☆This work was aided by a grant to Duke University by Davis & Geck, Inc., Brooklyn, N. Y.
☆Read at the meeting of the Society of University Surgeons, New Orleans, La., Jan. 29–31, 1948.
Identification
Copyright
© 1948 Published by Elsevier Inc.
