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Accidental injection of patent blue dye during gynaecological surgery: Lack of knowledge constitutes a system error
- Source :
- Anaesthesia Critical Care & Pain Medicine. 34:57-60
- Publication Year :
- 2015
- Publisher :
- Elsevier BV, 2015.
-
Abstract
- The authors report a case in which an intravenous injection of Patent Blue V dye instead of Indigo Carmine was given during routine gynaecological surgery. The patient presented with temporary arterial (spurious) desaturation and skin discoloration over a 48-hour period. Pharmacological differences between these dyes are described. Root cause analysis based on the ALARM (Association of Litigation and Risk Management) model is presented. The authors emphasise that use of this model should not be limited solely to describing and correcting well known systems errors such as working conditions or teamwork and communication. Furthermore, they conclude that insufficient knowledge must also be recognised as a systems error and as such should be sought out and corrected using similar strategies to those used to discover other contributory factors, without allocation of blame to any individual.
- Subjects :
- medicine.medical_specialty
media_common.quotation_subject
Hysterectomy
Indigo Carmine
Critical Care and Intensive Care Medicine
Blame
Gynecologic Surgical Procedures
Rosaniline Dyes
medicine
Humans
Lack of knowledge
Coloring Agents
Intensive care medicine
Risk management
media_common
Aged, 80 and over
Blue dye
Medical Errors
business.industry
General Medicine
Gynaecological surgery
Surgery
Anesthesiology and Pain Medicine
Accidental
Female
business
Root cause analysis
System error
Subjects
Details
- ISSN :
- 23525568
- Volume :
- 34
- Database :
- OpenAIRE
- Journal :
- Anaesthesia Critical Care & Pain Medicine
- Accession number :
- edsair.doi.dedup.....29f3562486a77932286e7e936c81dee7