Mistaken identity and use of lignocaine: case report

ABSTRACT

A 22 year old female patient was admitted for diagnostic curettage. She was clinically assessed and all her laboratory results revealed normal findings. Her medical status was categorized as American Society of Anesthesiology I Emergency [ASAIE].Anesthesia and recovery were uneventful until unifocal premature ventricular contractions [PVCs] appeared which later converted into multifocal PVCs and increased in number to 6/min. Lignocaine 2% [Xylocard 2%] was ordered but the nurse handed over lignocaine 20% [Xylocard 20%] to the doctor without reading the concentration and the dose. The full one-gram bolus was intravenously administered by mistake because the treating physician and nurse did not check the loaded Xylocard syringe. The collapsed patient was cared for with the appropriate measures. The patient was closely monitored in the intensive care unit and was later discharged. The necessary steps were taken to prevent the occurrence of similar incidents