title: Medication errors in anaesthetic practice: a report of two cases and review of the literature.
abstract: BACKGROUND
  Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications.
  
  
  OBJECTIVE
  To highlight the significance of medication errors in our practice and to discuss the best methods of prevention.
  
  
  METHODS
  A report of two cases of errors in the administration of drugs during the conduct of anaesthesia. The subsequent management of the cases is presented, and the findings from the literature are discussed.
  
  
  RESULTS
  In case 1, an adult male presented for herniorrhaphy and after induction with propofol 1mg/kg intravenously, Pancuronium bromide injection 4 mg was administered intravenously, in the place of suxamethonium chloride injection. In case 2, For induction of anaesthesia, 100mg of thiopentone sodium was administered in place of 25mg of the same drug because Thiopentone 1 gm vial was mistaken for Thiopentone 500 mg vial in a 2 year old girl. In both cases, the errors were detected early and there were no adverse sequelae.
  
  
  CONCLUSIONS
  Medication errors are a potential source of iatrogenic harm to patients undergoing anaesthesia. Strict adherence to principles as well as constant vigilance would minimize this problem.
authors.affiliation: Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.
authors.forename: E
authors.initials: E
authors.lastname: Ogboli-Nwasor
mesh_terms: D018686:Anesthetics, Intravenous / Q000008:administration & dosage* / Q000009:adverse effects; D002675:Child, Preschool; D004349:Drug Packaging; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008508:Medication Errors; D008875:Middle Aged; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage / Q000009:adverse effects; D010197:Pancuronium / Q000008:administration & dosage* / Q000009:adverse effects; D061214:Patient Safety; D013874:Thiopental / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D018686:Anesthetics, Intravenous; D006993:Hypnotics and Sedatives; D003473:Neuromuscular Nondepolarizing Agents; D010197:Pancuronium; D013874:Thiopental
keywords: Medication errors; anaesthetic practice; safety; vigilance