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Canadian Journal of Anesthesia 51:854-855 (2004)
© Canadian Anesthesiologists' Society, 2004

Correspondence

Drug labelling and a near miss in the labour suite

John A. C. Murdoch, MBCHB FRCA FFARCSI, Jeremy Lane, MD FRCPC and David H. Goldstein, MB BCH BAO MSC FRCPC

Kingston, Ontario

To the Editor:

An emergency Cesarean section in an otherwise healthy female gravida 1 para 0 occurred in the labour and delivery operating room. The fetus was entrapped by a non-relaxed uterus. The senior resident reached for the nitroglycerine and found the bottle depicted on the right of the FigureGo. Usually the bottle on the left is stocked in our labour suite, which is half the concentration of the one on the right. If he had not been vigilant and simply administered the usual "volume" the resultant overdose might have resulted in hypotension and possibly excessive uterine relaxation with associated risks of hemorrhage. Why highlight what was merely a "near miss" as surely the safety mechanism worked to prevent an adverse event occurring: the resident read the label prior to administration of the drug, he had the training and knowledge of the correct dose required and did not make an error? In the airline industry such reporting of near misses to organizations such as NASA’s Aviation Safety Reporting system has been credited with the reduction or uncovering of latent errors in that industry. The latent error here was the stocking of the wrong concentration of the drug on the anesthetic cart. We would contend that, as shown in the FigureGo, less than clear labelling by the drug company might have contributed. However, when the drug company was contacted to highlight the potential problem they replied that no action was required. Their labelling does meet Canadian standards as suggested by the Canadian Society of Hospital Pharmacists guidelines for drug labelling.



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  		FIGURE
 
A recent publication has highlighted the need to reduce avoidable adverse events in Canadian hospitals1 and reduction of drug error would go some way to achieving this. There are prior case reports of serious drug errors due to failure to read the ampoule label correctly2 and in one study of 2,000 incident reports, drug ampoule mix up occurred in 33% of "wrong drug" administration errors.3 Use of differing sizes of syringe and standardization of syringe labelling may go some way to reducing error but we still need to ensure that what is drawn up is the correct strength of the correct drug.4 A checking protocol in which two individuals check each drug has been suggested to reduce error.3 However, often in the emergency situation there is no one to check; in one survey of New Zealand anesthesiologists a second person was available to check for only 42% of respondents and only 1.5% used a routine second check for all drugs.5

Vigilance is key. We suggest that clear unambiguous labelling might be beneficial in reducing potential drug errors. Drug manufacturers must collaborate with health care providers to meet the challenge for safer health care.

References

1 Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170: 1678–86.[Abstract/Free Full Text]

2 Orser BA, Oxorn DC. An anaesthetic drug error: minimizing the risk. Can J Anaesth 1994; 41: 120–4.[Abstract/Free Full Text]

3 Currie M, Mackay P, Morgan C, et al. The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 596–601.[Medline]

4 Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004; 59: 493–504.[Medline]

5 Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law. N Z Med J 1995; 108: 185–7.[Medline]




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Can J Anesth, October 1, 2004; 51(8): 756 - 760.
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