Search research articles

ABOUT JoVE

Overview Leadership Blog JoVE Help Center

AUTHORS

Publishing Process Editorial Board Scope & Policies Peer Review FAQ Submit

LIBRARIANS

Testimonials Subscriptions Access Resources Library Advisory Board FAQ

RESEARCH

JoVE Journal Methods Collections JoVE Encyclopedia of Experiments Archive

EDUCATION

JoVE Core JoVE Business JoVE Science Education JoVE Lab Manual Faculty Resource Center Faculty Site

Terms & Conditions of Use

Search research articles

Related Experiment Videos

Drug errors in anaesthetic practice: case reports.

C N Mato¹, S Fyneface-Ogan

¹Department of Anaesthesia, University of Port Harcourt Teaching Hospital, Port Harcourt.

Nigerian Journal of Medicine : Journal of the National Association of Resident Doctors of Nigeria

|January 24, 2004

Summary

Unlabeled packaging changes for anesthetic drugs like ketamine hydrochloride and suxamethonium chloride led to medication errors. Vigilance and adherence to standard procedures are crucial to prevent patient harm.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by

Same author

ANAESTHETIC CHALLENGES IN A HIGH RISK PARTURIENT WITH MYASTHENIA GRAVIS UNDERGOING CAESAREAN SECTION UNDER SPINAL ANAESTHESIA.

East African medical journal·2016

Same author

Continuous spinal anaesthesia for caesarean section in a parturient with peripartum cardiomyopathy.

Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria·2014

Same author

A comparative study between caudal bupivacaine and bupivacaine co-administered with neostigmine for postoperative analgesia in children.

The Nigerian postgraduate medical journal·2014

Same author

Comparative effects of single shot low dose spinal bupivacaine only and bupivacaine with fentanyl on labour outcome.

Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria·2013

Same author

A comparison of the haemodynamic effects of lateral and sitting positions during induction of spinal anaesthesia for caesarean section.

International journal of obstetric anesthesia·2013

Same author

Anaesthetic management of a super morbidly obese patient for total abdominal hysterectomy: a few more lessons to learn.

African health sciences·2012

Area of Science:

Anesthesiology
Pharmacology
Patient Safety

Background:

Medication errors are a known risk in healthcare.
Drug administration errors can occur despite complex systems.
This study highlights three specific cases of such errors.

Purpose of the Study:

To report and analyze three cases of medication errors during anesthesia.
To emphasize the importance of consistent drug packaging in preventing errors.
To discuss the potential for serious patient harm due to these errors.

Main Methods:

Review of anesthetic records for three patients with drug administration errors.
Analysis of medication packaging changes at the University of Port Harcourt Teaching Hospital (UPTH).

Related Experiment Videos

Literature review on drug administration errors in anesthesia.

Main Results:

A change in packaging for ketamine hydrochloride (5% solution in dark brown bottles) and suxamethonium chloride (2 ml clear glass ampoules) occurred without prior notification.
This packaging change led to near-miss medication errors.
These errors had the potential for significant patient morbidity.

Conclusions:

Strict adherence to established procedures is essential for minimizing medication error risks.
Vigilance in drug administration is paramount to prevent patient morbidity and mortality.
Standardized and clearly identifiable drug packaging is critical in anesthetic practice.