Use of 400 µg/mL Peripheral Phenylephrine Infusions During Anesthesia: A Safety Initiative.

Area of Science:

• Anesthesiology
• Pharmacology
• Patient Safety

Background:

• Operating rooms typically use a 40 µg/mL phenylephrine solution.
• A patient received a 400 µg/mL phenylephrine infusion during general anesthesia, leading to iatrogenic hypertension.

Observation:

• A root cause analysis identified multiple factors contributing to the medication error.
• The patient's hypertension resolved after the incorrect phenylephrine infusion was discontinued.

Findings:

• A literature review supported the safety of using 400 µg/mL phenylephrine peripherally.
• The operating room successfully switched to a standardized 400 µg/mL phenylephrine infusion concentration.
• Post-implementation, only one medication error occurred, with no adverse events.

Implications:

• Standardizing phenylephrine concentration to 400 µg/mL in operating rooms can enhance patient safety.
• This quality improvement initiative demonstrates potential for increased efficiency and serves as a model for other institutions.