Most Errors Take Two or Three Mistakes To Get To A Crisis

I’d been practicing anesthesiology about 12 years and work daily around specialty nurses in the recovery room and nurse anesthetists who routinely administer powerful narcotics in a closely monitored environment.

I had gotten very comfortable walking through the recovery room and giving verbal orders to cover situations that went beyond normal criteria. I don’t remember the details of the case, but a patient was in a fair amount of pain and the normal narcotics weren’t keeping him comfortable. The nurse caring for him came up to me, described the situation and I said, “let’s give him some dilaudid.” I didn’t take into account that this was a new nurse and she was unfamiliar with dilaudid. About 20 minutes later, I was called to a respiratory arrest on the floor. The young nurse gave 2 mg (a relatively small volume but is WHOPPING large dose) to the patient and when he quickly got comfortable, she took him back to his room, where the dilaudid kept so sleepy and comfortable that he literally forgot to breath, turned blue and would have died if not for the pulse ox monitor and the floor nurse.

Like most errors, it took two or three mistakes to get to a crisis, but I started the mess by giving a vague and imprecise medication order to an inexperienced nurse.