Syringe Swap During Regional Block: A Case of Medication Error and Recovery. Kimberly Beres, DNAP, MHS, CRNA and Maria Cristina Gutierrez, MD | January 31, 2024

Syringe Swap During Regional Block: A Case of Medication Error and Recovery https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery In this WebM&M Case, a patient presented for open reduction and internal fixation of a fractured radius under an ultrasound-guided supraclavicular brachial plexus nerve block. The initial attempt at local anesthesia using 2% lidocaine was inadequate, necessitating a subsequent lidocaine injection, followed by the procedural block using 20 ml of 0.375% plain bupivacaine. The patient developed progressive dyspnea and diminishing oxygen saturation, prompting emergent intubation and initiation of mechanical ventilation. The respiratory distress was traced back to an inadvertent injection of vecuronium (a neuromuscular blocking agent) instead of the intended local anesthetic during the initial attempt at brachial plexus nerve block. The commentary outlines approaches to improving perioperative safety, including the importance of safety culture, improving medication labeling and packaging, and using medication checks, checklists, and handoffs to reinforce professional provider responsibilities.