A 65-year-old man with bipolar disorder was
scheduled for maintenance electroconvulsive therapy (ECT), a
procedure he had received dozens of times before. These procedures
are usually administered in the morning by an anesthesiologist.
Later in the morning, that anesthesiologist staffs the preoperative
anesthesia clinic. A second anesthesiologist in the group spends
the day in the operating room (OR) supervising three nurse
On the day of the scheduled ECT, the clinic
anesthesiologist called in sick. The service, which had no policy
to cover unexpected absences and rarely cancelled a case, scrambled
to try to cover the ECT procedure, finally asking the OR
anesthesiologist to attend on the case. He protested, noting that
he was already responsible for overseeing the anesthesia for three
surgeries in the OR. But finally, to avoid delays in the ECT
administration, he reluctantly agreed to come to the day surgery
unit to perform the quick (usually less than 10 minutes)
After the ECT was performed, the patient did not
wake up promptly as expected. The anesthesiologist checked his
medication cart and realized that he had inadvertently administered
the intermediate-acting muscle relaxant rocuronium, instead of the
short-acting agent succinylcholine. He later attributed this error
to being rushed and stressed, leading him to pull the wrong vial
from the refrigerator. He had never made this mistake before.
The patient was given more sedation to prevent
awareness and bag-and-mask ventilation to support his respirations.
After about 30 minutes, his neuromuscular blockade was
pharmacologically reversed with neostigmine. The patient was
informed of the error, and there were no long-term adverse
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