Description of Event or Problem · 1
ANESTHESIOLOGIST SET MRI PUMP TO ADMINISTER PROPOFOL DURING THE MRI. DOCTOR SET UP THE TUBING, PRIMED THE TUBING, AND SET UP THE RATE AND DOSE TO BE GIVEN. MRI SCAN BEGAN. APPROXIMATELY FIFTEEN (15) MINUTES LATER, DOCTOR NOTED THAT THE OXYGEN SATS WERE DECREASING, AND HE PLACED A NASAL TRUMPET TO ASSIST WITH OPENING THE AIRWAY. AFTER PLACING THE NASAL TRUMPET, DOCTOR NOTED THAT THE 1ST 50 ML BOTTLE OF PROPOFOL WAS EMPTY. FOUR (4) MINUTES LATER, DOCTOR THEN HUNG THE 2ND 50 ML BOTTLE OF PROPOFOL AFTER CONFIRMING THE RATE OF INFUSION AND THE VOLUME INFUSED ON THE MRI INFUSION PUMP THE PROPOFOL WAS RUNNING ON. MRI SCAN RESTARTED AT THAT TIME. TEN (10) MINUTES LATER, DOCTOR NOTED THAT THE SATS CONTINUED TO BE LOW AND STOPPED MRI SCAN; AT THAT TIME DOCTOR NOTICED THAT THE SECOND 50 ML BOTTLE OF PROPOFOL WAS EMPTY EVEN THOUGH THE MONITOR STATED IT HAD DELIVERED APPROXIMATELY 8-9 ML. DOCTOR SHUT OFF THE PROPOFOL AND DISCONNECTED IT FROM THE PATIENT AND HOOKED THE LACTATED RINGERS BACK UP AND STARTED INFUSION. DOCTOR STARTED BAG MASK VENTILATION ON PATIENT TO HELP ASSIST WITH RESPIRATIONS. PATIENT STABILIZED AND MRI COMPLETED. NO ADVERSE PATIENT OUTCOME.WHAT WAS THE ORIGINAL INTENDED PROCEDURE?MRI TO BE COMPLETED UNDER PROPOFOL SEDATION.DEVICE #1IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.DEVICE #2IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.