To The Editor
I’m writing to inform you of a near miss at our institution, a large community hospital. During my morning room set-up, I noticed a medication vial containing a white substance found on my anesthesia Pyxis® machine table top. This substance could have easily been mistaken for propofol as it was identical to our current propofol supply in vial shape, size, cap color, label color, solution color, and consistency, as evidenced in Figure 1. The substance was a product called Rotaglide® lubricant. It is used as a medical lubricant for guidewires.
As with any near miss or drug error, there were a series of unusual circumstances that led to this product being placed on an anesthesia table top. Following our institution’s investigation, it is known that we carry this product in a very limited quantity in our catheter lab and interventional radiology suites. The product is not stocked by our hospital pharmacy but through a separate supplier. It was brought to our operating room suites to show a surgeon who was looking for a new medical lubricant. The vial was left in the room for the surgeon to look at after he completed his case. During or after the case it remained in the OR and was evidently mistaken for an anesthesia medication, as evidenced by its placement on our anesthesia Pyxis® machine. Our hospital has since taken steps to make sure Rotaglide® lubricant remains secured until we find a suitable replacement that is not identical to propofol.
It was not all that long ago that we didn’t label syringes of propofol because it was the only “white stuff.” I hope this letter serves as a reminder to always read medication labels prior to drawing it up, as things are not always as they seem.
Susan Duerr-Trebilcock, CRNA, MS