FWD: RSDHope-Paralyzed by Mistake

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From: byrd45 (Original Message) Sent: 2/21/2006 4:52 PM
PARALYZED BY MISTAKE!

This next article is very near and dear to me due to an experience I suffered through back in 1992, a year before I was officially diagnosed. I had had RSD for about 18 years at this point. In 1985 I had been in an automobile accident and broken my back, had a lamenectomy/spinal fusion L5/S1 in 1987. It had failed and caused the RSD to spread to the legs.

Long story short, skip to 1992. The pain had worsened and so my Doctor in 1992 decided we should try some nerve blocks. Like the average person, I knew nothing about them at the time. I went in and had the block. They did not use a fluoroscope and at the time I didn't know how important they are to anyone getting a block. Well I paid a steep price that was almost even steeper.

The Doctor who performed the nerve block accidently pushed the needle into the spinal canal and drew spinal fluid. It had the unfortunate side effect of paralyzing me from the mid-chest down. I spent the next 20 hours unable to move my arms, legs, and anything below my chest. They couldn't admit me because it was an outpatient procedure and my insurance company at the time would not allow them to admit anyone who was in for an outpatient procedure! It didn't seem to matter what my condition was.

At the same time the Doctor who treated me had passed me off to the Doctor who relieved him, who then passed me off to the one who relieved him, and so forth. Each successive Doctor more annoyed at the previous Doctor for "leaving me with them". The first Doctor had been very upset that "this had happened to him" in the first place. He made sure to mention to every nurse and doctor he encountered that this had not "happened to him" ever before. I tried to point out to him that it had actually "happened to me" but he seemed oblivious to my plight. At the time I had no idea that what I was experiencing might not "wear off", as he kept assuring me it would do any minute. If I did I probably would have been scared to death.

They finally kicked me out of the ambulatory care unit at hour 23.5 of the treatment. I had gotten some feeling back in my legs, not very much but some. But since the insurance company would not let them admit me, they had no choice but to check me out before i was there for 24 hours. Amazing huh? I was pretty much dragged up to my second floor apartment by a couple of friends since I still could not walk when I got home. The feeling came back by the next day. I was very, very lucky. I learned a few years later that others had similar experiences and never got the feeling back and were permanentl paralyzed. Now you see why the following story is so important.

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MEDICATION SAFETY ALERT

PREVENTING ERRORS WITH NEUROMUSCULAR BLOCKING AGENTS


ISMP recently issued a Safety Alert called "Paralyzed by Mistakes," which warned about inadvertently giving neuromuscular blocking agents such as pancuronium to patients who aren't receiving ventilator support. This can lead to respiratory arrest. Some patients have died or incurred permanent injuries as a result of these errors.
ISMP notes that some of the errors are due to look-alike packaging and labeling. In one case, an ED nurse administered pancuronium instead of flu vaccine because the vials and labeling looked very similar. Look-alike drug names have also caused problems. In one case vancomycin was misread on a faxed medication record as vecuronium.

Giving the neuromuscular blocking agent after the patient is extubated has resulted in serious problems, too. In one case, an infusion bag of vecuronium was left in a patient's room after ventilator support had been removed. The bag was later mistaken as potassium chloride infusion and administered to the patient.

Serious patient injuries have also been caused by the opposite problem i.e., administering the neuromuscular blocking agent too soon, before the patient is intubated.

Some errors have resulted from preparing syringes from a multiple-dose vial and neglecting to label them. In one case, an unlabeled syringe of vecuronium ended up in a supply of saline flush syringes and was given to a 3-year old child.


To read the rest of the story click on the link below;

http://www.rsdhope.org/Showpage.asp?PAGE_ID=129&PGCT_ID=3645