Reduce the Risk of Tragedies Due to Ampule Mix-Ups

January 2024

You’ll see emphasis on preventing errors with meds in ampules...due to a fatal mix-up.

Recently, a pregnant patient received intrathecal injections of digoxin instead of bupivacaine during delivery...after selection of the wrong amp. This led to digoxin toxicity, and the patient died.

Help ensure safety with meds in amps...and educate other clinicians (nurses, anesthesia staff, etc) about risks.

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