A near-miss drug swap: proposing a system fix to the quality lead
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Yesterday, at the end of a laparoscopic appendectomy, your resident drew up what she believed was ondansetron from the "antiemetics" bin of the anesthesia cart. When she read the syringe label against the vial before injecting, she saw the vial was rocuronium. Nothing was given and the patient was unharmed. A pharmacy check found a box of rocuronium restocked into the ondansetron bin of two carts. You filed an event report. Dr. Priya Raman, the department's patient safety officer, has asked to meet you.
Your task: discuss the event with Dr. Raman and propose how the department should prevent it. Do not discuss the pharmacology of rocuronium. You have 8 minutes; a warning sounds at 6 minutes.3