C N Mato1, S Fyneface-Ogan. 1. Department of Anaesthesia, University of Port Harcourt Teaching Hospital, Port Harcourt.
Abstract
BACKGROUND: Error is inherent in any complex human endeavour. It is therefore not unusual for these to occur in drug administration. We report three cases of such errors. METHOD: The anaesthetic record of 3 patients who had errors in drug administration and discussion of the relevant literature. RESULT: Through the years in anaesthetic practice at the University of Port Harcourt Teaching Hospital (UPTH), our Pharmacy has always supplied standard ketamine hydrochloride in a dark brown bottle containing 10 mls of the 5% solution. Suxamethonium chloride on the other hand was always supplied in a 2 ml clear glass ampoule. A change in this known packaging without prior notification resulted in near misses, all of which had the potential for serious morbidity. CONCLUSION: A strict adherence to standard procedure is necessary to minimize the risk, since there is no substitute for vigilance if morbidity and mortality is to be prevented.
BACKGROUND: Error is inherent in any complex human endeavour. It is therefore not unusual for these to occur in drug administration. We report three cases of such errors. METHOD: The anaesthetic record of 3 patients who had errors in drug administration and discussion of the relevant literature. RESULT: Through the years in anaesthetic practice at the University of Port Harcourt Teaching Hospital (UPTH), our Pharmacy has always supplied standard ketamine hydrochloride in a dark brown bottle containing 10 mls of the 5% solution. Suxamethonium chloride on the other hand was always supplied in a 2 ml clear glass ampoule. A change in this known packaging without prior notification resulted in near misses, all of which had the potential for serious morbidity. CONCLUSION: A strict adherence to standard procedure is necessary to minimize the risk, since there is no substitute for vigilance if morbidity and mortality is to be prevented.