Syringe swap and similar looking drug containers: A matter of serious concern

Abstract

Medication error is a leading cause of morbidity and mortality in anesthesia and critical care unit. We present
a case report of a 25 years old female patient, scheduled for emergency lower segment caesarean section (LSCS)
under spinal anesthesia. Due to a syringe swap, inj. thiopentone sodium was injected inadvertently, instead of inj.
ceftazidime. We had to administer general anesthesia to ventilate the patient, the patient which was otherwise
unnecessary in this case. Patient was successfully extubated and shifted to postoperative anesthesia recovery
room. We present a second case report of a 45 years old male patient with chronic obstructive pulmonary
disease (COPD) admitted in Intensive Care Unit (ICU). This patient inadvertently received atropine instead of
metronidazole and was successfully managed. These incidents highlight the importance of proper drug location,
double checking of the drugs, and proper anesthesia resident education.