Journal of Pharmacovigilance

Abstract

Life Threatening Hyperkalemia during Cardiopulmonary Bypass: An Avoidable Drug Error

Minati Choudhury, Ujjwal Kumar Chowdhury, Lokendra Kumar and Ritu Airan

Cardiopulmonary bypass (CPB) is a routine part of open heart surgery. Sodium bicarbonate is an essential component of prime solution to neutralize the prime and maintain physiological pH. Potassium chloride and sodium bicarbonate were supplied at our institute one year before were in identical ampoules. They were same in shape, size, color and lettering. Such ampoules introduce potential sources of error including life threatening situation in the operating room.

A medication error related to administration of excessive potassium caused ventricular fibrillation and cardiac arrest immediately at the initiation of cardiopulmonary bypass (CPB).The purpose of this report is to improve perfusionist training in intravenous drug management, the use of drug ampoules with distinct labels, and the development of a standardized color code system for labels on all the drugs used by the perfusionist. Furthermore, it is recommended that all drug errors (drugs used in the operating room) be reported to the Agencies responsible for drug packaging in order to identify patterns in perfusionist drug errors, and to facilitate implementation of effective drug identification systems.