What’s New in the Patient Safety World
September 2014
Another Blue Dye Eye Mixup
In our May 20, 2014
Patient Safety Tip of the Week “Ophthalmology:
Blue Dye Mixup” we discussed an unfortunate case
where methylene blue was used during cataract surgery rather than trypan blue and noted we suspected this risk could be
present at many hospitals or ambulatory surgery centers.
Well, in fact, it
has happened before. An almost identical case in North Carolina just resulted
in a $1.5 million malpractice award (Upchurch
2014). The patient was undergoing
cataract surgery and the ophthalmologist ordered VisionBlue
(trypan blue) to stain the cataract so it could be safely removed. But a nurse instead
brought methylene blue and handed it to a surgical technician, who gave it to the
ophthalmologist. Both the nurse and the technician testified they announced
that the drug was methylene blue but the ophthalmologist apparently never heard
that. The patient became permanently blind in that eye and developed glaucoma
in it as well.
Though we don’t want to minimize the importance of
communication and personal accountability in such cases, it is very clear there
is a huge system issue here. The system actually put those healthcare
workers and the patient in a vulnerable position that allowed the mistake to
happen. It is very much akin to the concentrated potassium chloride issue
of the past in which nurses accidentally administered fatal doses of
concentrated KCl to patients. There was little reason
for nurses to have access to vials of concentrated KCl
yet we placed them on nursing units and it was simply a matter of time until
someone unwittingly drew up a syringeful and
administered a fatal dose. Our eventual system fix was to remove vials of
concentrated KCl from floor stock on nursing units.
We need to do the same thing in this scenario. We need to
eliminate the opportunity for nurses or technicians and ophthalmologists to
inadvertently allow methylene blue in a patient’s eye. As we noted in our May 20, 2014 Patient Safety Tip of the Week “Ophthalmology:
Blue Dye Mixup” this is really an example
of confusion about LASA (look-alike,
sound-alike) drug pairs. So if you are an OR or
ASC that does eye surgeries, you should add this drug pair (methylene blue and trypan blue) to your LASA list and take appropriate
precautions to minimize the chance they might be mixed up. If you are a
facility that only does eye cases, you probably have no need for methylene blue
and therefore should not stock it at all.
In other facilities where you may have a legitimate need for methylene blue
(for example, it is used to help identify leaks in some surgeries or to help
identify tissue in need of debridement in others) you clearly need to store the two blue dyes separately. If
you have a dedicated “eye” room and can store all the medications and materials
for eye surgery there (or in an automated dispensing cabinet dedicated to
ophthalmology) make sure that methylene blue is not in those areas. It might
even be worth considering putting
warning labels on methylene blue stating “not for eye cases” or something
to that effect. We are unaware of any “tallman”
lettering conventions for this drug pair. A logical one might be “METHYLENE
blue” and “TRYPAN blue” but you’d have to make sure that these choices are not
confused with any other drugs or substances you stock.
This is a serious situation that could put your patients,
your staff, and your reputation at risk. It deserves your immediate attention
to ensure it doesn’t happen in your facilities.
This is also a great example of our failure to disseminate
valuable lessons learned promptly. The North Carolina case occurred in 2008,
the California case (CDPH
2014) in 2013. We don’t know if the North Carolina case had been discussed
in the ophthalmology literature before. We’re also willing to bet that these
two cases were not the only ones. With the concentrated KCl
issue it took many years for people to recognize that these cases were
happening at multiple different hospitals and ultimately implement a system
change. Let’s hope it does not take many years for hospitals and ASC’s to
implement system changes here.
Some of our previous
patient safety columns involving ophthalmology issues:
June 5, 2007 “Patient
Safety in Ambulatoy Surgery”
March 11, 2008 “Lessons
from Ophthalmology”
June 8, 2010 “Surgical
Safety Checklist for Cataract Surgery”
June 2012 “Tailored Timeouts for Ophthalmologists”
May 20, 2014 “Ophthalmology:
Blue Dye Mixup”
References:
Upchurch K. Jury awards cataract patient $1.5M in
malpractice suit. The Herald-Sun Aug. 20, 2014
CDPH (California Department of Public Health). 2014. Intake
Number CA00368387.
http://cdph.ca.gov/certlic/facilities/Documents/2567AltaBates-0HT111-Alameda-20010511.pdf
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