A first step toward understanding patient safety

Kim, Kyoung Ok

A 4-year-old child (height, 106 cm and weight, 16.7 kg) was admitted to the hospital for excision of a preauricular cyst. A physician-in-training (resident) in the ear-nose-throat (ENT) department telephoned an anesthesia resident about a sedative dose of ketamine. The anesthesia resident said, "10 milli would be enough. " The anesthesia resident interpreted the word "milli" as short for milligram. However, the ENT resident considered that "milli" was short for milliliter and wrote the order as follows: inject 500 mg/10 cc of ketamine over 1 min. This was 50 times the therapeutic dose. A nurse was concerned about the dose and asked the resident "Is this right?" to verify the order. The resident approved the medication by answering the nurse, "Yes, give it. " The nurse executed the order. This accident was discovered when the parent reported that the child had not woken up from sedation for several hours after finishing the computed tomography scan. Fortunately, the child recovered fully without complications.