Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Andrew B Thyen; Russell K McAllister; Lisa M Councilman

Commentary

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

December 8, 2010

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6(4):244-246.

View more articles from the same authors.

This case report discusses how an error with no lasting patient harm served as a catalyst for organizational efforts on process improvement, protocol review, and safeguard enhancement to ensure safe delivery of epidural analgesia.

PubMed citation

Available at

Related Resources From the Same Author(s)

Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.

May 13, 2009

Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology.

October 5, 2022

Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities.

June 22, 2011

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

September 30, 2009

Analysis of patient safety risk management call data during the COVID‐19 pandemic.

January 27, 2021

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.

September 13, 2006

Leveraging the continuum: a novel approach to meeting quality improvement and patient safety competency requirements across a large department of medicine.

November 14, 2018

The quality and safety track: training future physician leaders.

September 4, 2013

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

May 2, 2012

Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.

May 25, 2011

Oncologic errors in diagnostic radiology: a 10-year analysis based on medical malpractice claims.

November 10, 2021

What we can do about maternal mortality—and how to do it quickly.

November 14, 2018

The role of technology in clinician-to-clinician communication.

August 14, 2013

The Triangle Model for evaluating the effect of health information technology on healthcare quality and safety.

March 21, 2012

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

September 1, 2021

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

September 22, 2010

Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice

January 22, 2020

A paradigm shift to balance safety and quality in pediatric pain management.

March 6, 2013

Electronic prescribing improves medication safety in community-based office practices.

March 17, 2010

Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation.

September 20, 2023

The use of technology for urgent clinician to clinician communications: a systematic review of the literature.

January 7, 2015

Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.

May 29, 2019

Exploring health care professionals' perceptions of incidents and incident reporting in rehabilitation settings.

July 1, 2015

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

The nurse's role in the causation of compensable injury.

October 12, 2011

Applying fault tree analysis to the prevention of wrong-site surgery.

March 11, 2015

Program access, depressive symptoms, and medical errors among resident physicians with disability.

January 12, 2022

Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries.

July 31, 2013

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

January 18, 2023

Older patients' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries.

September 24, 2008

A quality improvement initiative to improve pediatric discharge medication safety and efficiency.

August 16, 2023

Critical care nurses’ physical and mental health, worksite wellness support, and medical errors.

July 14, 2021

How can never event data be used to reflect or improve hospital safety performance?

May 19, 2021

National survey on the effect of oncology drug shortages on cancer care.

April 10, 2013

Failure mode and effects analysis: a comparison of two common risk prioritisation methods.

May 4, 2016

Observation for assessment of clinician performance: a narrative review.

November 11, 2015

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

November 1, 2006

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

March 21, 2018

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Remedies sought and obtained in healthcare complaints.

September 7, 2011

A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting.

November 30, 2016

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.

January 14, 2015

Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.

May 30, 2018

Operating room to intensive care unit handoffs and the risks of patient harm.

July 22, 2015

Frailty, gaps in care coordination, and preventable adverse events.

July 6, 2022

Children and the opioid epidemic: age-stratified exposures and harms.

October 21, 2020

Adverse patient safety events during the COVID epidemic.

May 17, 2023

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff.

March 28, 2018

Supratherapeutic dosing of acetaminophen among hospitalized patients.

December 5, 2012

Overrides of medication-related clinical decision support alerts in outpatients.

January 8, 2014

Radiology research in quality and safety: current trends and future needs.

April 19, 2017

Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.

September 12, 2007

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods.

January 21, 2015

Disclosure and apology: nursing and risk management working together.

August 8, 2018

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital.

February 12, 2014

Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge.

December 1, 2021

Impact of a clinical pharmacy admission medication reconciliation program on medication errors in "high-risk" patients.

February 19, 2014

Prevention by design: construction and renovation of health care facilities for patient safety and infection prevention.

September 28, 2016

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

October 21, 2009

Night-time communication at Stanford University Hospital: perceptions, reality and solutions.

November 15, 2017

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial.

December 12, 2012

False dawns and new horizons in patient safety research and practice.

December 20, 2017

Systematic biases in group decision-making: implications for patient safety.

November 5, 2014

Raising and responding to frontline concerns in healthcare.

September 11, 2019

Vital signs: maternity care experiences — United States, April 2023.

September 6, 2023

Did duty hour reform lead to better outcomes among the highest risk patients?

November 4, 2009

Communication errors in dispatch of air medical transport.

December 8, 2010

Primary care collaboration to improve diagnosis and screening for colorectal cancer.

May 3, 2017

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

March 24, 2021

Use of administrative data to find substandard care: validation of the complications screening program.

October 26, 2005

A multiple-drawer medication layout problem in automated dispensing cabinets.

December 19, 2012

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence.

July 15, 2015

Challenges faced in providing safe care in rural perinatal settings.

November 25, 2009

Simple strategies to avoid medication errors.

March 21, 2007

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Teaching hospital five-year mortality trends in the wake of duty hour reforms.

August 7, 2013

A randomized trial of nighttime physician staffing in an intensive care unit.

June 5, 2013

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.

April 29, 2015

Impact of preoperative briefings on operating room delays.

November 26, 2008

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

January 7, 2015

Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study.

January 23, 2019

A national study links nurses' physical and mental health to medical errors and perceived worksite wellness.

March 21, 2018

Assessing the performance of aging surgeons.

January 30, 2019

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study.

November 16, 2011

Critical events during land-based interfacility transport.

February 12, 2014

Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research.

January 8, 2014

Frequency of medication administration timing error in hospitals: a systematic review.

March 29, 2023

Performance of a fail-safe system to follow up abnormal mammograms in primary care.

September 8, 2010

Epidemiology of adverse events in air medical transport.

October 1, 2008

Reducing adverse events in blood transfusion.

October 5, 2005

Medical-surgical nurse leaders' experiences with safety culture: an inductive qualitative descriptive study.

November 9, 2022

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Does increased schedule flexibility lead to change? A national survey of program directors on 2017 work hours requirements.

September 23, 2020

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

October 3, 2018

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

February 22, 2023

Strategies to prevent healthcare-associated infections through hand hygiene.

July 30, 2014

Related Resources

WebM&M Cases

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.

August 30, 2023

WebM&M Cases

Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.

June 28, 2023

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.

September 21, 2022

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean delivery.

April 22, 2020

Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study.

January 29, 2020

Burnout and Resilience and Quality and Safety Programs in Obstetrics and Gynecology.

August 21, 2019

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

July 10, 2019

WebM&M Cases

Failure to Rescue the Mother

July 2, 2019

A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit.

June 19, 2019

Obstetric practice guidelines: labor's love lost?

June 5, 2019

Patient Safety in Obstetrics and Gynecology.

May 29, 2019

In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats.

May 22, 2019

Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.

May 8, 2019

How to reduce maternal mortality rates in the United States.

May 8, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

April 17, 2019

Why do hundreds of US women die annually in childbirth?

March 27, 2019

New mother number 14.

March 20, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.

January 23, 2019

Reversing the rise in maternal mortality.

January 16, 2019

Annual Perspective

Maternal Safety

December 22, 2018

Deadly Deliveries.

August 8, 2018

Nurses' knowledge and teaching of possible postpartum complications.

August 30, 2017

The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.

May 25, 2016

WebM&M Cases

Monitoring Fetal Health

January 1, 2015

Office-based anesthesia: safety and outcomes.

August 13, 2014

ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.

April 30, 2014

Patient safety in obstetrics and obstetric anesthesia.

April 23, 2014

See More About The Topic

Labor and Delivery

Risk Managers

Quality and Safety Professionals

Engineers

Anesthesiology

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site