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A patient was scheduled for surgery to remove a cancerous eye. Before the procedure, the anesthesiologist removed some spinal fluid to decrease intracranial pressure. He placed the fluid in a small vial, which he marked "S.F." (for "spinal fluid") and set aside to reinject after the surgery.
An ophthalmology resident who was supposed to do a biopsy entered the operating room (OR) to pick up the eye. The surgeon hadn't yet removed it, so the resident said he'd come back later. Before leaving, he placed an unlabeled vial of glutaraldehyde-a formaldehyde-like preservative--on a table in the OR.
A nurse noticed the vial the resident had left behind and asked what was in it. Thinking she was referring to the vial the anesthesiologist had used, the surgeon told her it was spinal fluid. Because she didn't want an unlabeled vial in the OR, the nurse marked it accordingly.
After the operation was successfully completed, the patient was turned on his side to have the spinal fluid reinjected. Forgetting that he'd filled only one vial, the anesthesiologist injected the contents of both vials. The patient immediately went into cardiopulmonary arrest. During the resuscitation, the resident returned and asked where his vial of glutaraldehyde was. The cause of the arrest was then apparent. The patient died later that day.
Unlabeled vials or syringes containing any substance should never be left in a patient care area--or anywhere else. To do so is to invite a tragic error like this one. Nurse-managers should discuss this matter with the pharmacy and laboratory to make sure appropriate labels are provided.