Accidental injection of patent blue dye during gynaecological surgery: Lack of knowledge constitutes a system error

• Published in: Anaesthesia critical care & pain medicine Vol. 34; no. 1; pp. 57 - 60
• Main Authors: Laukaityte, Edita, Bruyère, Marie, Bull, Amanda, Benhamou, Dan
• Format: Journal Article
• Language: English
• Published: France Elsevier Masson SAS 01.02.2015
• Subjects: Aged, 80 and over; Anesthesia & Perioperative Care; Coloring Agents - adverse effects; Dyes; Female; Gynecologic Surgical Procedures - adverse effects; Humans; Hysterectomy; Indigo Carmine; Medical education; Medical Errors; Medication error; Methylene blue; Patent blue; Rosaniline Dyes - adverse effects; Medical education; Medication error; Dyes; Indigo carmine; Patent blue; Methylene blue
• ISSN: 2352-5568; 2352-5568
• DOI: 10.1016/j.accpm.2014.08.002

Abstract The authors report a case in which an intravenous injection of Patent Blue V dye instead of Indigo Carmine was given during routine gynaecological surgery. The patient presented with temporary arterial (spurious) desaturation and skin discoloration over a 48-hour period. Pharmacological differences between these dyes are described. Root cause analysis based on the ALARM (Association of Litigation and Risk Management) model is presented. The authors emphasise that use of this model should not be limited solely to describing and correcting well known systems errors such as working conditions or teamwork and communication. Furthermore, they conclude that insufficient knowledge must also be recognised as a systems error and as such should be sought out and corrected using similar strategies to those used to discover other contributory factors, without allocation of blame to any individual.