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Spinal anesthesia performed 5 hours after dalteparin - how an interprofessional communication breakdown led to an immediate institutional policy change.
Abstract Number: S1C-8
Abstract Type: Case Report/Case Series
Antepartum patients admitted to the ward may require emergency procedures for which neuraxial anesthesia is often preferred. However, these patients may also be on thromboprophylaxis. We report an interprofessional communication breakdown that resulted in a spinal anesthetic performed 5 hours after prophylactic dalteparin was administered, and how it resulted in an immediate institutional policy change.
A 33-year-old G1P0 was admitted with threatened preterm labor. During admission, she was placed on bedrest and dalteparin was initiated. She delivered preterm soon after transfer to the labor ward, then required a manual removal of placenta. The nurse (RN) accompanying her to the OR was relieving the primary RN and not familiar with the patient. During OR sign-in, her medical history, lab work and drug allergies were reviewed by the team and the anesthesiologist consented the patient for a spinal anesthetic with the obstetric and RN providers present. A spinal anesthetic was performed at 03:10; it was selected due to the history of high BMI (35 kg/m2) and bronchospasm under general anesthetic. It was then discovered that dalteparin 5000 IU was given at 22:00. The error was disclosed to the patient immediately postoperatively and neurological exams were performed hourly for 12 h. There were no long-term sequelae. This case was immediately brought to the hospital's Patient Safety Committee and institutional changes were quickly implemented.
Obstetric patients are often transferred between multiple areas in the hospital and managed by various care providers increasing opportunities for a breakdown in interprofessional handover. This incident drove immediate changes in our hospital policy: First, a distinctive neon wristband will be placed on all patients receiving thromboprophylaxis on admission. Second, if surgery is required, the RN accompanying the patient will ensure the medication administration record is updated and brought to the OR. Lastly, thromboprophylaxis has been added to the OR sign-in checklist to be specifically discussed by the obstetric providers. Unfortunately, sometimes it takes a serious incident to highlight a deficient area of patient safety. We now have a system to mitigate any further risk to future patients. This case illustrates the importance of a robust safety checks to ensure parturients are not put at increased risk of complications.
1. ASRA Practice Advisory. RAPM 2010