Ketamine Use Fatal Error, Lessons Learned

July 22, 2015    |   By: Calevir

The unfortunate death of a 55 year old man at the University of Vermont Medical Center resulting from a five-fold overdose of Ketamine leads to many lessons learned for safe medication policies, medication administration and timeliness of action plan implementation for hospitals and EMS:

Lesson #1 – Consider the danger of using multi-dose vs. single-dose vials as an organization-wide policy. Most importantly due to the risk inherent in the use of multi-vials but also to reduce wastage of medication that may be in short supply. In this case, Ketamine was available in multi-dose vials and five doses were drawn up instead of only the one ordered by the physician.

Lesson #2 –  Medication administration policies should be monitored and enforced, particularly if multi-dose vials are in use.  In this case, the hospital policy was to only draw up the medication ordered and intended for administration, yet common practice by nursing, particularly in emergent situations, was to draw up multiple doses at one time in order to be ready for subsequent orders.

Lesson #3 – The importance of timely evaluation of the cause of such events and implementing action plans. In this case, although there is some discrepancy among those involved, there was evidence that the five-dose vials had not yet been removed from the medication boxes up to 49 days following the fatal event.

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