residual

Inadvertent residual IV med bolus

Joanie Cook's picture

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My student and I are evaluating a case where a patient received an inadvertent bolus of residual high-concentration norepinephrine which was still present in a port access line after an infusion. We occasionally get reports of similar events happening with propofol for patients coming out of the OR. And I recall that there was at least one published case many years ago involving a neuromuscular blocker. I'm wondering if anyone has had similar events at your hospital, and if you have any ideas how to "hard wire" preventing this type of event?

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