Obstetric Anaesthesia Annual Scientific Meeting 2023

Accidental administration of 30,000 IU of unfractionated heparin during an elective lower segment caesarean section for placenta praevia

Authors: B O’Connor, A O’Donoghue, T Drew, N Hayes

Department of Anaesthesiology, The Rotunda Hospital, Dublin, Ireland

Introduction:

•Human factors are well known to cause error in the clinical setting, particularly in a dynamic environment such as an operating theatre.

•With potential for significant morbidity and mortality, it is imperative to analyse critical incidents as a result of human error so that future occurrences can be minimised.

Case Report:

•We present the case of a 38-year-old female, with a history of placenta praevia, who presented for an elective lower segment caesarean section (LSCS) and was mistakenly administered 30,000 units of unlabelled, unfractionated heparin (UFH), as part of co-loading of intravenous fluids after neuraxial anaesthesia was performed.

Timeline of Events

•38-year-old female, with a history of placenta praevia, presented for an elective LSCS

•Cell salvage was set up in theatre due to the high risk of bleeding

•30,000 IU heparin added to 1 litre bag of 0.9% NaCl and hung on cell salvage machine – Not labelled

•Underwent routine IV access, monitoring, and sub-arachnoid block,

•Co-loaded with warmed 0.9% NaCl

•No prewarmed Hartmann’s solution available so prewarmed 0.9% NaCl solution used

•Prior to surgical start, nursing staff noticed that heparinised saline missing from cell salvage machine

•No labels present on saline bag - clinical suspicion that co-loading fluid was heparinised saline

•Case postponed

•Coagulation studies showed an unrecordable activated partial thromboplastin time (aPTT) and rotational thromboelastometry (ROTEM) showed a significantly prolonged clotting time (CT) on INTEM analysis of 696 seconds (normal CT 109–225s) (Fig 1).

•Consulted with Haematology. The patient was administered protamine sulphate and her coagulation studies were monitored to ensure no recurrent anticoagulation after reversal of UFH.

•Admitted to labour ward for CTG monitoring in the interim

•Regular neurological examination was performed and after four hours showed complete recovery of motor and sensory function.

•Ten hours following the initial error, the patient’s coagulation studies had normalised, and she successfully delivered via LSCS under neuraxial anaesthesia.

Outcome:.

•Admitted to HDU post-operatively requiring Bakri balloon with a 1.7L blood loss.

•Uneventful course in HDU

•Open disclosure was conducted at the time of the initial drug error and apologies provided

•The patient and her partner were debriefed immediately after the incident and followed up over the postnatal period

•Ward follow up performed with no neuraxial complications

•Discharged home 5 days post-operatively

Root Cause Analysis

•Step 1: Identify the main problem – Medication Error

•Step 2: Identify the major factors

•Step 3: Take each major factor and identify possible factors contributing to the problem

•Step 4: Investigate the factors identified

Discussion:

•Our team utilised the fishbone (Ishikawa) diagram to analyse the contributing factors that led to this medication error [Figure2].

•We found the key contributing factors to include;

•Poor communication between staff

•Lack of education with rarely used equipment

•New staff in an unfamiliar working environment

•Individual human errors

•Deviation from standardised protocol in both drug preparation and IV fluid preparation

•Following root cause analysis of this clinical incident

•Extra education and training sessions provided for all staff on cell salvage machine

•Training provided to theatre staff regarding preparation of high risk medication

•While it is not possible to fully eliminate all these factors, root cause analysis has been shown to minimise future adverse events and improve patient safety.

References

1.Online library of Quality, Service Improvement and Redesign tools. Cause and effect (fishbone). Accessed 2 February 2023

https://www.england.nhs.uk/wp-content/uploads/2021/12/qsir-cause-and-effect-fishbone.pdf

Obstetric Anaesthesia Annual Scientific Meeting 2023

Accidental administration of 30,000 IU of unfractionated heparin during an elective lower segment caesarean section for placenta praevia

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