A nurse anesthetist at Abbott Northwestern Hospital in Minneapolis accidentally administered a paralytic to a female patient who'd been scheduled to undergo spinal anesthesia for surgery, according to a Minnesota Department of Health report.
The paralytic was drawn up in error. The patient, who was conscious and lightly sedated when she received the paralytic, and who recovered without harm, later told state investigators she "felt unable to breathe."
After realizing the mistake had occurred, the surgical staff converted from spinal to general anesthesia. The patient's vital signs and oxygen levels never deviated from acceptable ranges, according to the report.
The paralytic is typically given to surgical patients who receive general anesthesia and are already deeply sedated, according to the investigation.
The state didn't cite the hospital for the error. While staff at Abbott Northwestern did not provide anesthesia in a "safe, organized manner," say investigators, they reported no deficiencies in care after reviewing the hospital's anesthesia delivery policies and procedures, interviewing 3 anesthesia providers, observing a CRNA prepping a patient for surgery and talking to 3 patients about the care they received.
The investigators credited Abbott Northwestern with taking adequate corrective action in response to the incident, including investigating the root cause of the error, changing medication delivery policies and procedures, educating staff on proper medication safety, having the hospital's quality and patient safety department assess the incident and ensuring new medication delivery processes are being followed.
An Abbott Northwestern spokesman declined to comment.
Daniel Cook
