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Blindness From Undiluted Injection

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kc_case_2012_blind

Blindness From Undiluted Injection

By Christine Allen, BSN, RN, CCM

Related to: Education, Medication, Nursing, Other Specialties


Description

A 50-year-old patient received an undiluted intraocular injection, resulting in left eye blindness.

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Key Lessons

  • Medication administration processes that require dilution inherently pose increased risk of error.
  • Office clinics need written policies that specify who is responsible for preparation and administration of undiluted medications.
  • Medication dilution should be done by licensed providers, and verified by a second provider for accuracy.
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Clinical Sequence

A patient with baseline vision of 20/20 presented to her ophthalmologist with a two-week history of progressive visual changes affecting her left eye. The physician diagnosed toxoplasmosis (parasitic infection) of the left eye, and prescribed oral antibiotics and antiparasitics. At first, the patient noted some improvement in vision but suffered persistent gastrointestinal side effects from the antibiotics. 


At a follow-up visit several weeks later, the physician observed that the patient’s vision had begun to deteriorate. The patient told the ophthalmologist that she stopped taking her medications due to the intolerable side effects.  The physician discussed an alternative treatment option involving an injection of the antibiotic directly into the eye. They discussed the risks and benefits of intraocular injections, and the patient consented to the procedure.


In preparation for the injection, a technician retrieved undiluted clindamycin from the pharmacy, and confirmed with a fellow that it was the correct medication. The technician then drew up the medication and gave it to the ophthalmologist, who injected it into the patient’s eye.  The patient experienced abrupt vision loss. The ophthalmologist initially believed the vision loss was related to increased pressure during the infusion, and he ordered an angiogram, followed by intraocular washings with saline.


When the patient’s vision did not return, the ophthalmologist transferred her to a specialty hospital, where she underwent a pars plana vitrectomy (removal of all fluid from eyeball). During the PPV the ophthalmologist observed ischemia of the retina.  The patient’s vision loss persisted, and she was referred to a retinal specialist. She has undergone seven surgical procedures, but despite interventions she still has no meaningful vision in her left eye. 


Through further investigation, the ophthalmologist and his fellow concluded that the patient likely received an undiluted dose of the antibiotic. There was some confusion amongst the fellow, the technician and the ophthalmologist about who was responsible for dilution. The ophthalmologist generally relied on the office staff and fellow to draw up and dilute the medication.  When he injected the medication he thought it had already been diluted; however, based on the injury suffered, he is no longer sure. The ophthalmologist disclosed the error to the patient, and accepted full responsibility. The office has implemented a new policy requiring that all medication dilution be witnessed and signed off on, by either a fellow or an NP.

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Allegation

The patient sued the clinic and her ophthalmologist, alleging negligence in the preparation and administration of clindamycin, resulting in permanent vision loss.

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Disposition

The case was settled against the ophthalmologist for more than $1 million.

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Analysis

  1. The patient was accidentally injected with a dose of clindamycin that was 15 times stronger than the intended dose. The ophthalmologist believed the medication had already been diluted, and was unaware that he was injecting a concentrated dose of the antibiotic
    Medication administration errors are more likely to occur when staff members have to manipulate the medication to achieve a desired dose. Pre-packaged dosing in a single unit that is ready for administration can significantly reduce the risk of an adverse drug event.
  2. The physician did not confirm that the medication he was injecting had been appropriately diluted.
    The “five rights” of medication administration are not exclusive to nurses. Any provider who administers medications is also responsible for ensuring that they have the right patient, the right drug, the right dose, the right route, and the right time. These five quick checks can help reduce medication errors.
  3. The practice did not have a formal process for preparing and administering medications.
    Policies for diluting medications should require that a licensed provider perform the dilution and a 2nd provider verify accuracy before administration.
  4. The physician took full responsibility for negligently administering the undiluted medication.
    When negligence is clear and the defense experts and defendant himself cannot conclude that an action met the standard of care, a case does not have to be adversarial and drawn out for a long period of time. The defense team can shift to negotiating a settlement over monetary damages. This can still be somewhat lengthy, sometimes involving an outside mediator; however, settlement negotiations are far less burdensome and time-consuming than a case that goes to trial or arbitration for a verdict.
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April 11, 2012
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