Medical mishaps: Mistaken identity

The BMJ has recently focused on the underreporting of adverse events and near misses in the NHS. The clinical review article entitled “Reporting and preventing medical mishaps” (BMJ 2000; 320:759-63) stressed the importance of reporting incidents, as near misses offer numerous benefits over adverse events. In the light of this and recent events we would like to draw attention to the following. Working in a busy plastic surgery unit, we have noticed that a variety of water, saline, and lignocaine ampoules all look virtually identical in terms of bottle design and labelling (see figure ). Our concerns about the potential for a mistake being made were confirmed recently during administration of a local anaesthetic wrist block, when a vial of water was mistaken for lignocaine. Fortunately, in this case mistaking water for lignocaine had no serious consequences other than requiring re-injection with local anaesthetic. However, the potential consequences of an accidental intravenous injection of lignocaine (such as while preparing an intravenous infusion) are obvious. We have contacted the manufacturers (B Braun), who are aware of the similarity in labelling and packages of these products. They state that there is nothing they can do about it and referred us to the Medicines Control Agency, which is ultimately responsible for overseeing product labelling. When we contacted the agency it said that it was aware of the problem. Hopefully, in reporting this near miss, we will have alerted others to this potential danger. The Medicines Control Agency may even look further into its labelling guidelines if others have had similar experiences.