title: Drug errors in anaesthetic practice: case reports.
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.
  
  
  METHODS
  The anaesthetic record of 3 patients who had errors in drug administration and discussion of the relevant literature.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Anaesthesia, University of Port Harcourt Teaching Hospital, Port Harcourt.
authors.forename: C N
authors.initials: CN
authors.lastname: Mato
authors.forename: S
authors.initials: S
authors.lastname: Fyneface-Ogan
mesh_terms: D000293:Adolescent; D000700:Analgesics / Q000008:administration & dosage*; D000758:Anesthesia / Q000009:adverse effects / Q000592:standards; D005260:Female; D006801:Humans; D007649:Ketamine / Q000008:administration & dosage*; D008297:Male; D008508:Medication Errors; D008875:Middle Aged; D009467:Neuromuscular Depolarizing Agents / Q000008:administration & dosage*; D013390:Succinylcholine / Q000008:administration & dosage*
chemical_list: D000700:Analgesics; D009467:Neuromuscular Depolarizing Agents; D007649:Ketamine; D013390:Succinylcholine