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There but for the grace …

BMJ 2001; 323 doi: (Published 07 July 2001) Cite this as: BMJ 2001;323:56
  1. Neville W Goodman (, consultant anaesthetist
  1. Bristol

    Itoo have injected the local anaesthetic bupivacaine into an intravenous cannula instead of into an epidural catheter. I have injected the antibiotic cefuroxime, thinking it was the anaesthetic thiopentone. I once failed to dissolve the full amount of thiopentone, and it took me a couple of cases to realise I was using an inappropriately dilute solution. I have flushed a cannula at the end of an operation only to realise that I had injected the muscle relaxant pancuronium instead of saline. What prevented me from injecting another muscle relaxant, suxamethonium, into a conscious patient was no more than the flip of a coin. Having injected the opioid fentanyl and the induction dose of anaesthetic, I reached for the suxamethonium syringe. There wasn't one, but there was another syringe labelled fentanyl that contained the suxamethonium. I have injected 15 000 units of heparin intravenously thinking it was 3000 units. This last was after checking with an experienced anaesthetic sister. When we read the label, we both saw what we …

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