Authors:
Alan F. Merry FANZCA, Diana H. Shipp MRPharmS, Jocelyn S. Lowinger MBBS
Abstract
The administration of medications is central to anaesthetists’ care of patients. Errors are inevitable in any human endeavour, but should be distinguished from violations. The incidence of medication errors in anaesthesia has been estimated as 1 per 13 000 administrations, excluding errors in recording. Adverse medication events follow a proportion of these errors. Labelling is a key element of medication safety. There is a long-standing need for improvements in the labelling of ampoules and vials. An international standard exists for labelling syringes used during anaesthesia (ISO 26825). Australia has recently released national recommendations for labelling lines and injectable medications that complement this and other relevant standards. The provision of at least some medications in pre-filled syringes would reduce the number of steps involved in medication administration, increase the certainty that syringe labels are correct and probably reduce medication errors. Pre-printed, peel-off flag labels on ampoules and vials are a less expensive alternative to pre-filled syringes to facilitate correct labelling. The medication name on user-applied labels should be matched to that on the relevant ampoule or vial at the time of drawing up any medication. All lines and catheters should be labelled. Any medicine or fluid that cannot be identified (e.g., in an unlabelled syringe or other container) should be considered unsafe and discarded. Reducing adverse medication events will require the engagement of individual anaesthetists.