A Fatal Ampule Swap

Although I wasn’t an expert witness on this lawsuit, I was asked by the hospital to investigate the death of Justin Micalizzi, (read on for an explanation why I use his real name) a healthy 11-year-old who underwent I&D for an ankle abscess. He underwent a very routine and safe anesthetic, until he developed severe hypertension, bradycardia, V-tach, then asystole, and never recovered. Several experts were asked to investigate, and my examination of the paper anesthesia record showed nothing abnormal. Nothing came from the investigation, and his death remained a mystery, until…. about ten years later when it was revealed by an anonymous source who knew the anesthesia group, that Justin’s anesthesiologist had mistakenly picked up the phenylephrine vial thinking it was the ondansetron vial. A classic case of ampule swap, but in this case, it involved a fatal dose (>100x the normal dose) of phenylephrine. This case has led me on a career-influencing path of reforming the way in which we administer medications in the operating room. I now strongly believe that all medications administered by anesthesia personnel should be available in pre-filled syringes with Joint Commission appropriate labels. It seems crazy to me that we are responsible for drawing up medications from vials at the point of administration, in a non-sterile, inaccurate environment. Even if prefilled syringes are available to anesthesia personnel, there’s no current available technology that will guarantee the prevention of the wrong medication being administered. But, it will eliminate ampule swap, needlestick injuries, and will greatly decrease the incidence of using the same syringe and ampule on multiple patients.

As a result of this tragedy, Justin’s mom Dale has devoted her life to becoming a patient-safety and disclosure advocate. You can read her story, as well as access many types of related materials here: http://justinhope.tumblr.com/

There are many morals to this story but here are the most important:

1. Lobby your hospital and pharmacy to provide only pre-filled medication syringes. If they insist on providing you ampules, make sure that no two ampules that look similar are near each other in the drug tray. Potentially fatal ampules, such as phenylephrine should be located in a separate (but conveniently accessed) location in the OR. The cost compared to everything else in the OR is minuscule, and irrelevant.

2. Make a pledge to yourself that you will never, ever again, for the rest of your life administer a medication without: 1) triple-checking that it is indeed the medicine you intended to draw up from the vial; and 2) triple-checking that it is indeed the correct syringe you think it is. If you do, I guarantee that you will catch a potential syringe or ampule swap at least once in your career. Almost everyone I know has admitted to this.

  1. lalexander2014

    I read Dales letter titled ” the letter it took 10 years to write ” so many years ago ,it feels like. I have waited every year for a letter with the truth of my Childs death to come to me. People need to understand the weight a parent carries without transparency. Thanks Dr.Litman for writing this. Lenore Alexander http://www.Leahslegacy.org

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