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Due to a drug shortage of bupivacaine, the hospital was no
longer able to purchase compounded bupivacaine infusions
from an outsourcer. Pharmacy staff had just begun mixing
bupivacaine infusions in 100-mL bags of 0.9% sodium chloride and were also mixing gentamicin infusions (not available
commercially) in 100-mL bags. Similar-looking pharmacy
labels had been applied to the front of the bags, and a red
"Epidural Use Only" label had been affixed to the front of the
bupivacaine bag. Although barcode scanning was used when
refilling the ADC, only the first product in a batch loaded into
each bin was scanned. In this case, the technician scanned 1
of the correct bupivacaine infusions but did not notice that 1
of the 5 similar-looking bags loaded in that bin contained gentamicin. Several days later, an anesthesia practitioner removed
the gentamicin bag from the ADC and did not notice the error.
Although nurses in L&D employed a BCMA system routinely prior to administering medications, the technology was
not used at all by anesthesia practitioners. Thus, the anesthesia practitioner administered the gentamicin by the epidural
route, believing the bag contained bupivacaine.
The patient complained of significant pain during labor
and delivered her baby 2 hours later. The mother was stable
post delivery, and the baby had high Apgar scores. The error
was finally noticed when a nurse discontinued the epidural
solution post delivery; however, 69 mL of gentamicin had
infused. The anesthesia practitioner administered normal
saline via the epidural route for 10 hours to dilute the gentamicin in the epidural space.

Prior Errors
Since 2000, Institute for Safe Medication Practices (ISMP)
has described more than a dozen errors that occurred in the
United States and the United Kingdom involving the IV
administration of epidural bupivacaine in L&D units, including 5 deaths of young mothers.1-5 Prior errors involving epidural administration of IV antibiotics have also occurred.
Most of the fatalities occurred with IV administration of epidural bupivacaine before IV lipid emulsion therapy was recommended as an antidote by the American Society of Regional
Anesthesia and Pain Medicine (ASRA).6 Events occurring
before (2006) and after (2016) widespread knowledge of lipid
emulsion therapy as an antidote are provided as examples.

2006 Event
A 16-year-old woman in labor died after accidental IV
administration of fentaNYL with bupivacaine instead of
penicillin G.3 The L&D workflow favored collection of all
supplies at the start of labor or induction. Therefore, the epidural medication had been brought into the patient's room
before it was prescribed so it was ready for anesthesia staff
when needed. The bag of penicillin G was also in the room.
Both infusions had been prepared in 150-mL bags, and both
bags were labeled with the same orange-colored pharmacy

Hospital Pharmacy 54(3)
labels. A large pink warning label, "For Epidural Use Only,"
was on the front of the epidural bag, and a small pink label
was on the back. However, the nurse misread the pharmacy
label, and the warning labels did not catch her attention. Her
perception of risk was not high, as she thought she had penicillin G in hand, not an epidural infusion.
Several weeks before the event, the hospital's L&D unit
had implemented a BCMA system. However, most of the
L&D patients bypassed the admissions department, where
identification (ID) bands were typically applied, and were
admitted directly to the unit without an ID band. Therefore,
the patient did not have an ID band on when the nurse was
administering what she thought was penicillin G. Thus, the
BCMA system was not used. Within minutes of infusing the
fenta NYL with bupivacaine IV, the patient experienced cardiovascular collapse. Although a healthy infant was delivered by cesarean section, the medical team was unable to
resuscitate the mother.

2016 Event
A healthy 21-year-old woman in labor received IV fentaNYL
with bupivacaine instead of penicillin G.5 Shortly after epidural placement, the patient began experiencing perioral
numbness and tinnitus followed by stupor, seizures, hypotension, and tachycardia. It was quickly noticed that the nurse
had mistakenly grabbed and administered a 100-mL bag of
epidural fentaNYL (2 µg/mL) with bupivacaine (0.25%),
thinking it was penicillin G. Naloxone and an IV bolus of
lipid emulsion was administered, followed by a lipid emulsion infusion, with patient improvement in just a few minutes. Fetal heart rate never dropped below 130 beats per
minute, and the patient delivered a healthy infant with high
Apgar scores. It was prompt recognition followed by prompt
administration of the IV lipid emulsion that saved this young
woman and her infant.

Safe Practice Recommendations
Due to the risk of mix-ups between epidural analgesia and
IV antibiotics in L&D settings, consider the following
recommendations.
Prescribing.
Initiate and verify orders. If a patient requires IV antibiotics
and/or epidural analgesia, require the physician or anesthesia
professional to initiate the required orders and have a pharmacist verify the orders before either infusion is brought to
the patient's bedside.
Consider less toxic anesthetics. When appropriate, consider the use of other local anesthetics for epidural analgesia
that may be less cardiotoxic than bupivacaine (e.g., ropivacaine), in case the epidural analgesia is inadvertently administered IV.7

Hospital Pharmacy - June 2019

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