Reporting of critical incidents shows how errors occur

BMJ 1995;311:1368 (18 November)

Letters

Reporting of critical incidents shows how errors occur

EDITOR,--R E Ferner draws attention to the confusion that canbe caused when different drugs are labelled in an identicalmanner.¹ I would like to draw attention to another problem.

Drugs may be presented in two or more strengths in identicallysized and labelled ampoules. In my hospital, through the reportingof critical incidents, two examples of such confusion have recentlycome to light. In the first incident 30 mg of morphine was confusedwith 10 mg, and in the second incident 10 mg of diamorphinewas given instead of 5 mg. In both cases the junior doctor,on rotation from one hospital to another, expected only oneparticular strength to be available.

While no excuses can be given for such errors, it is too easyto read what one expects to see. I agree that in the ideal situationchecking would help prevent such errors, but this may not . . . [Full text of this article]

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