Clinical Scenario:
A 24 year old female presents overnight having fallen whilst intoxicated. She has a visual deformity of her right forearm. X-ray confirmed a distal radius fracture with marked angulation. The decision was made to reduce the fracture under sedation. Given her risk of vomiting it was decided to use ketamine as the sedation agent.
The doctor asked the nurse to draw up some ketamine and prepare the patient for sedation whilst he reviewed another patient. Prior to starting the procedure the nurse informed the doctor that they currently only stocked the higher dose of ketamine (50mg/ml). However the doctor did not hear this and assumed that the ketamine was of the more commonly used lower dose (10mg/ml).
Procedure:
The doctor intended to give the patient 30mg of ketamine (an appropriate dose for procedural sedation), but instead was erroneously given 150mg (an anaesthetic dose).
Outcome:
Fortunately the patient did not experience any serious adverse effects, just a sensation of disequilibrium for a few hours.
What was the mistake:
Incorrect dosing can have serious consequences for patients. Both doctors and nurses have a responsibility to ensure that the correct dose of drug is administered. In this case, poor communication (and night shift sleep deprivation!) was the main factor in the patient being given the wrong dose. Breakdown in communication is the leading cause of all errors in healthcare and as such all healthcare providers have a responsibility to be mindful of their communication with patients and colleagues.
