Medication errors: a matter of serious concern

The incidence of medications errors is increasing and the exact incidence is likely greatly underestimated and under-reported. Although the majority of these errors occur due to lack of knowledge of or failure to follow accepted protocols, look alike medication containers are the primary cause in many cases of drug error related morbidity or even mortality. With the number of drugs and the number of pharmaceutical companies manufacturing the same drug on an increase, the incidence is likely to increase. It is a universal problem that can be found in any operating room throughout the world, as demonstrated by the multi-national representation of many reports on this subject in the literature. This editorial supplements a case report, the 'Clinipics' Registered page and a special article on the topic of hazards of look-alike drug containers published in this issue of Anaesthsia, Pain and Intensive Care. The authors also attempt to present strategies to reduce these medication errors. The development of a non-blame environment where errors are openly reported and discussed and regulations for labeling the drug containers, vials and ampoules is stressed

Syringe swap and similar looking drug containers: a matter of serious concern

Medication error is a leading cause of morbidity and mortality in anesthesia and critical care unit. We present a case report of a 25 years old female patient, scheduled for emergency lower segment caesarean section [LSCS] under spinal anesthesia. Due to a syringe swap, inj. thiopentone sodium was injected inadvertently, instead of inj. ceftazidime. We had to administer general anesthesia to ventilate the patient, the patient which was otherwise unnecessary in this case. Patient was successfully extubated and shifted to postoperative anesthesia recovery room. We present a second case report of a 45 years old male patient with chronic obstructive pulmonary disease [COPD] admitted in Intensive Care Unit [ICU]. This patient inadvertently received atropine instead of metronidazole and was successfully managed. These incidents highlight the importance of proper drug location, double checking of the drugs, and proper anesthesia resident education