oa Southern African Journal of Anaesthesia and Analgesia - The adverse effects of inadvertent intraoperative intravenous phenylephrine administration : a case report : case study

Volume 18, Issue 4
  • ISSN : 2220-1181
  • E-ISSN: 2220-1173



Inadvertent intravenous injection of 1% phenylephrine (10 mg) induced severe hypertension and tachycardia in a previously healthy female patient undergoing elective gynaecological surgery. This medical error was investigated using the critical-incident technique that is available in our department. This case report highlights the cardiovascular sequelae of phenylephrine overdose and the human factor that is associated with a medication error. We discuss these two factors, as well as the organisational factors that contributed to this medical error, in order to prevent its recurrence.

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