Journal of Pharmacovigilance

Ujjwal Kumar Chowdhury

Publications

• Case Report
  Life Threatening Hyperkalemia during Cardiopulmonary Bypass: An Avoidable Drug Error
  Author(s): Minati Choudhury, Ujjwal Kumar Chowdhury, Lokendra Kumar and Ritu AiranMinati Choudhury, Ujjwal Kumar Chowdhury, Lokendra Kumar and Ritu Airan
  
  Cardiopulmonary bypass (CPB) is a routine part of open heart surgery. Sodium bicarbonate is an essential component of prime solution to neutralize the prime and maintain physiological pH. Potassium chloride and sodium bicarbonate were supplied at our institute one year before were in identical ampoules. They were same in shape, size, color and lettering. Such ampoules introduce potential sources of error including life threatening situation in the operating room. A medication error related to administration of excessive potassium caused ventricular fibrillation and cardiac arrest immediately at the initiation of cardiopulmonary bypass (CPB).The purpose of this report is to improve perfusionist training in intravenous drug management, the use of drug ampoules with distinct labels, and the development of a standardized co.. View More»
  DOI: 10.4172/2329-6887.S2-003

  Abstract PDF