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- T Andrew Bowdle, Srdjan Jelacic, Craig S Webster, and Alan F Merry.
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. Electronic address: bowdle@u.washington.edu.
- Br J Anaesth. 2023 Jan 1; 130 (1): 141614-16.
AbstractAn error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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