Improving Clinical Learning Environments for Tomorrow's Physicians.
N Engl J Med. 2014 Jan 27;
Authors: Nasca TJ, Weiss KB, Bagian JP
"Approximately 2 months ago, I had a patient where I accidently administered a wrong dose of fentanyl during a procedure. The patient developed severe hypotension, and the procedure had to be temporarily halted until we could get her blood pressure back up. My attending was close by. He responded quickly. Ultimately, no harm was done. "The reason I believe this happened is that during a procedure I'm sometimes required to administer fentanyl and must dilute it during the procedure. There are two dilutions, either to directly administer by syringe, or for use as an intravenous drip. We do this dilution . . .
PMID: 24467307 [PubMed - as supplied by publisher]