The adverse effects of inadvertent intraoperative intravenous phenylephrine administration: a case report

Authors

  • Kingsley Enohumah Tallaght Hospital
  • Immanuel Hennessy Tallaght Hospital
  • Rob Whitty Tallaght Hospital
  • Judith Connolly Tallaght Hospital

Keywords:

Human error, drug overdose, phenylephrine

Abstract

Inadvertent intravenous injection of 1% phenylephrine (10 mg) induced severe hypertension and tachycardia in a previously healthy female patient undergoing elective gynaecological surgery. This medical error was investigated using the criticalincident technique that is available in our department. This case report highlights the cardiovascular sequelae of phenylephrine overdose and the human factor that is associated with a medication error. We discuss these two factors, as well as the organisational factors that contributed to this medical error, in order to prevent its recurrence.

Author Biographies

Kingsley Enohumah, Tallaght Hospital

Specialist Registrar Department of Anaesthesia and Intensive Care Medicine Tallaght Hospital

Immanuel Hennessy, Tallaght Hospital

Senior House Officer Department of Anaesthesia and Intensive Care Medicine Tallaght Hospital

Rob Whitty, Tallaght Hospital

Consultant Anaesthetist Department of Anaesthesia and Intensive Care Medicine Tallaght Hospital

Judith Connolly, Tallaght Hospital

Consultant Anaesthetist Department of Anaesthesia and Intensive Care Medicine Tallaght Hospital

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Published

2012-05-22

Issue

Section

Case Studies