Inadvertent Injection of Ciprofloxacin Instead of Ropivacaine Through Epidural Catheter.

Purpose: Patient harm is often due to medication errors related to neuraxial and peripheral misconnection. We report a case of inadvertent injection of ciprofloxacin into the epidural space and discuss the strategies that could prevent such an incident. Summary: A 74-year-old woman presented a recurrence of an ovarian cancer. The recent discovery of an intrabdominal recurrence on CT-scan led us to propose a new surgical procedure. A thoracic epidural analgesia was performed prior to general anesthesia. Postoperative pain was controlled with patient-controlled epidural analgesia (PCEA) with ropivacaine-epinephrine. During the first night, abdominal pain appeared. During the second day, a nurse discovered that the bag connected to the pump contained ciprofloxacin and not ropivacaine. After aspiration of 2.5 ml sent to laboratory for analysis, the epidural catheter was removed. The investigation revealed the different causes leading to such an error. Three days after, the patient returned home, without any adverse symptoms. Conclusion: This is the first report of the inadvertent administration of ciprofloxacin into the epidural space via a patient-controlled epidural analgesia technique. As there is no effective treatment for such errors, we discuss the neurological risk of ciprofloxacin and prevention strategy mainly based on organizational and human factors.

Communicate About Quality and Safety: Let's Think Outside the Box! Experience From a Cancer Center.

BACKGROUND AND OBJECTIVES: While the priority of caregivers in any health care establishment is patient care, they are often constrained by time and cannot fully devote themselves to projects aiming at improving the quality and safety of care. Although the culture of quality is widespread in health care establishments, the quality and safety department team must continue to improve existing procedures and develop new ones, in order to reinforce the take-home message that safety is of paramount importance. Since good communication is a key factor in the success of quality plans, the quality and safety team in our establishment is placing special emphasis on "out of the ordinary" activities that take professional carers out of their daily routines, arouse their curiosity, and increase their adherence to quality procedures. METHODS: The issues addressed during these activities are based on the year-round continuous assessment of in-house procedures. Only those that have been deemed essential for safe care are focused upon. Most of the activities that are implemented have already been tried and tested in the fields of industry and aviation, and they all have a fun, collaborative, and creative component. Their impact and effect are assessed by carrying out the same assessments as those used at the beginning on the project. RESULTS: These innovative activities, which have received strong support from the staff, have had a positive effect on interdepartmental cooperation, on the adherence to the new methods presented, and on ensuring that information is made available to the greatest number of professionals. They have allowed the staff to acquire and consolidate new professional knowledge and have promoted good practice. CONCLUSION: This new program of activities has considerably improved the safety culture within our establishment. While the relationship between the skills of professionals and patient safety is clear to all, the message needs to be delivered in an original way that makes a lasting impression, in addition to using "standard" communication methods such as plenary meetings. The bottom line is to get as many professionals as possible fully adherent to the culture of quality, since quality is everyone's business and health care procedures are constantly evolving. Based on our experience, we provide a set of activities that can be improved and adapted according to the setting in which it is used.

La certification V2014 et les équipes de soins.

V2014 CERTIFICATION AND NURSING TEAMS.: V2014 certification focuses on the management of care-related risks. During the certification visit, the caregiver sometimes has to explain to the experts from the French National Health Authority their understanding of the approaches undertaken in their department, as well as their own contribution to their implementation. Users' representatives are also consulted. The next version of the certification, in 2020, will aim to give even more meaning to nursing practices through the analysis and the relevance of the care provided.