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A 78-year-old woman on an intensive care unit was receiving intravenous nitroglycerin and lidocaine (lignocaine) to treat angina and congestive heart failure. Her nurses carefully titrated the medications, using a separate infusion pump for each. To avoid confusion, the nurses labeled each pump with the name and concentration of the drug being infused.
One morning, just before change of shift, the night-shift nurse replaced the two infusion bags and their tubing according to hospital protocol. Shortly after the day-shift nurses arrived, the patient complained of angina. Her nurse increased the rate of the nitroglycerin infusion, but the patient still had pain. Soon she became lethargic and confused.
The nurse called the patient's doctor, who suspected lidocaine toxicity. Discontinuing the lidocaine, he too increased the rate of the nitroglycerin infusion.
By this time, the patient was stuporous, but still mumbling about chest pain. Suspecting she'd taken a turn for the worse, the nurse called in the family.
Just then, another nurse discovered what was wrong. The nightshift nurse had accidentally reversed the infusion bags when replacing them on the pumps. Nobody had read the labels on the bags; instead, they had assumed the labels on the pumps were correct. As a result, the patient had been receiving increasing amounts of lidocaine and no nitroglycerin. She was indeed experiencing a toxic reaction to the lidocaine.
The doctor ordered the lidocaine temporarily stopped and the nitroglycerin restarted. Within a few hours, the patient was responsive and free of pain.
You can imagine how serious such an error could be. Never rely on an infusion pump's label: Read the label on the infusion container. And when checking the patient's infusion or making any adjustments to the setup, trace it from the container, to the pump, to the patient.