Wis. Surgeon Sanctioned in Patient's Epinephrine Death

Sarasota, FL (WorkersCompensation.com) – Clear communication and accurate labeling in the operating room is critical, according to a recent report from Becker’s Spine Review. Orthopedic surgeon Molly Day, MD from UW Health in Wisconsin has been sanctioned after a patient died during surgery as a result of a communication and mislabeling error.

According to the medical board order, the patient was scheduled for a routine shoulder arthroscopy with Dr. Day in October 2021. In the course of preparing for the surgery, a nurse asked Dr. Day if epinephrine should be prepared "in the bag or on the field." According to the order, Dr. Day responded, “either” and then pointed to a 30mL vial, assuming that a small amount would be drawn out and added to the usual anesthesia. Dr. Day did not specify how much of the epinephrine to mix with the Marcaine being used for the anesthesia.

The scrub technician for the surgery drew out all of the epinephrine into a syringe. The scrub technician stated that she labeled the syringe “epi”, however Dr. Day stated it was not labeled. In addition to Dr. Day’s statement, two other orthopedic surgeons issued sworn statements that syringes were inconsistently labeled in their surgeries as well. 

Upon beginning the surgery, Dr. Day injected the full syringe without verifying dosage. The patient subsequently developed arrhythmia, coded, and died. 

As a result, the medical board is requiring Dr. Day to take six hours of education on effective communications, as well as root cause analysis. Both the nurse and the scrub technician are still employed with the facility, and Dr. Day is pursuing the required education according to a statements released to The Wisconsin State Journal, and Becker’s. 

Some statistics have shown death from general anesthesia are relatively low, at around 11 to 16 deaths per 100,000 surgeries, with the rates escalating with the increase in complexity and complications of the surgery. Anesthesia studies have shown however, that verbal orders and miscommunication involving the use of epinephrine for surgeries are not all that uncommon. 

Given in proper amounts, epinephrine is commonly added to the saline irrigation fluid during surgery to reduce bleeding and improve visualization. Some studies have suggested that the use of epinephrine in this manner potentially reduces the incidents of extreme low blood pressure. In some cases epinephrine is also used for cardiac arrest. 

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