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Southern African Journal of Anaesthesia and Analgesia

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

KO Enohumah, H Immanuel, R Whitty, J Connolly

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.



http://dx.doi.org/10.1080/22201173.2012.10872856
AJOL African Journals Online