Case Study: Almost Thumbs Down

The 45 year old plumber presented to the Emergency Department (ED) with a deep laceration to his right thumb which occurred while he was cutting some sheet metal. The wound was bleeding profusely and the JMO advised the patient that it would require suturing. The JMO carefully examined the wound for any foreign body and she then tested the power and sensation in the patient's thumb. Having ascertained that there did not appear to be any nerve or tendon injuries, the JMO proceeded to suture the wound. The nurse had set up a tray with some local anaesthetic, suture material and a suture pack. The JMO drew up the lignocaine that had been left on the tray and proceeded to insert a ring block in the patient's right thumb. After inserting less than 0.5 mL of local anaesthetic, the JMO suddenly realised that the nurse had left lignocaine with adrenaline, rather than plain lignocaine on the tray. She immediately stopped the procedure and called the ED registrar to review the patient. Fortunately, in view of the fact that the JMO had noticed the error so quickly and only a small amount of local anaesthetic had been inserted, there were no adverse sequelae. The JMO promptly apologised to the patient for the error.

The inadvertent use of lignocaine with adrenaline in wounds involving digits is a common source of error and adverse outcomes in the ED. JMOs are reminded to always personally check any medication prior to administration and to ensure that lignocaine with adrenaline is not used in wounds when there is a risk of vascular compromise from the vasoconstrictive effects of adrenaline.

These case histories are based on actual medical negligence claims, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.

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