title: [Risk management by reporting critical incidents. Vitamin K and ephedrine mix-up at a birthing unit].
abstract: BACKGROUND
  Errors of medication are frequent causes of hazards to patients. It has been suggested that containers that look alike constitute a risk of such errors. In this article, we present an example of how reporting incidents of potential risks, can be applied in their clinical management.
  
  
  METHODS
  As part of a medical technology assessment project on risk management in a delivery department, the staff were encouraged to report incidents that could create a potential risk to patients. The incidents were assessed by a project group as either a general problem to patient safety or a solitary incident. If considered a general problem, procedures should be changed and implemented in the department.
  
  
  RESULTS
  Two incidents were reported, where ephedrine and adrenaline were found in a box supposed to contain vitamin K for new-born babies. These were considered a general problem by the project group, and the procedure for storing and managing ephedrine and adrenaline in the delivery department was changed to prevent new cases.
  
  
  CONCLUSIONS
  Near misses occur more often than actual errors, and we argue that, as they are easier to discover, it is important to learn from them and thus prevent further incidents. A forum should be set up to exchange experiences of acknowledged risks, hazards, analytical results and preventive solutions.
authors.affiliation: H:S Hvidovre Hospital, gynaekologisk-obstetrisk afdeling, MTV-enheden, anaestesiafdelingen.
authors.forename: J
authors.initials: J
authors.lastname: Seidelin
authors.forename: B L
authors.initials: BL
authors.lastname: Pedersen
authors.forename: T S
authors.initials: TS
authors.lastname: Mogensen
mesh_terms: D003718:Denmark; D004349:Drug Packaging; D004356:Drug Storage; D004809:Ephedrine / Q000008:administration & dosage* / Q000009:adverse effects; D004837:Epinephrine / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007231:Infant, Newborn; D008508:Medication Errors / Q000517:prevention & control; D012308:Risk Management / Q000379:methods*; D014812:Vitamin K / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D014812:Vitamin K; D004809:Ephedrine; D004837:Epinephrine