Unlabeled Containers Lead to Patient's Death

摘要

A tragic medication error in late 2004 claimed the life of a 69-year-old Seattle woman, caused in large part by the presence of unlabeled basins of solution in the interventional radiology procedure room. During coil placement under cerebral angiography to repair a brain aneurysm, the patient was accidentally injected with an antiseptic skin preparation solution, chlorhexidine, instead of contrast media. Both solutions were clear and available on the sterile field in unlabeled basins. The hospital's recent decision to switch antiseptics from a brown povidone-iodine solution to a clear chlorhexidine solution resulted in a latent failure-two look-alike, clear solutions on the sterile field that were previously distinguished by color. This latent failure was revealed when the unlabeled solution basins were mixed up.