Re: Coroner issues anaesthetic safety warning after patient death; Inspect before you inject
Dear Editor,
This tragic death raises significant questions and highlights serious risks in current practices surrounding local anaesthetic administration. In this case, the emphasis is on the dangers of miscommunication between theatre staff, particularly when verbal instructions are given without written confirmation. The fallibility of this process, unfortunately, requires incidents like this to underscore the need for altering common practices and calls for standardized protocols to prevent future errors.
It would be unjust to place responsibility on any single individual, as ultimately, team members share in a multistep, interactive process to ensure the correct and safe administration of local anaesthetic. Similar to time-out and double-check procedures, introducing a critical confirmatory step before administration demands a moment of focus and re-evaluation, fostering communication and adherence to safety protocols.
As always, we must derive lessons from such cases to prevent future mistakes and use this opportunity to drive changes in both personal and national practice. A prompt such as "Inspect Before You Inject" could serve as a useful reminder before the nurse hands over the drug-filled syringes to the surgeon, with a documented prescription that has been confirmed by the anaesthetist. This would encourage shared responsibility for confirming the drug dose, mixture, and volume prior to administration.
Rapid Response:
Re: Coroner issues anaesthetic safety warning after patient death; Inspect before you inject
Dear Editor,
This tragic death raises significant questions and highlights serious risks in current practices surrounding local anaesthetic administration. In this case, the emphasis is on the dangers of miscommunication between theatre staff, particularly when verbal instructions are given without written confirmation. The fallibility of this process, unfortunately, requires incidents like this to underscore the need for altering common practices and calls for standardized protocols to prevent future errors.
It would be unjust to place responsibility on any single individual, as ultimately, team members share in a multistep, interactive process to ensure the correct and safe administration of local anaesthetic. Similar to time-out and double-check procedures, introducing a critical confirmatory step before administration demands a moment of focus and re-evaluation, fostering communication and adherence to safety protocols.
As always, we must derive lessons from such cases to prevent future mistakes and use this opportunity to drive changes in both personal and national practice. A prompt such as "Inspect Before You Inject" could serve as a useful reminder before the nurse hands over the drug-filled syringes to the surgeon, with a documented prescription that has been confirmed by the anaesthetist. This would encourage shared responsibility for confirming the drug dose, mixture, and volume prior to administration.
Competing interests: No competing interests