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- Dhanesh D Binda, Mauricio Gonzalez, Victoria Rosales, William Black, and Rafael Ortega.
- From the Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
- A A Pract. 2023 Jul 1; 17 (7): e01705e01705.
AbstractThe delivery of drugs from the manufacturer to the hospital is a complex process. Despite numerous safeguards, lapses may occur, creating the potential for patient harm. Recently, an urban tertiary care medical center received a shipment of isoflurane bottles labeled for veterinary use. This error was not identified until the veterinary isoflurane reached the operating room automated medication dispensing system. No patients received the anesthetic. This report describes how such an error occurred, explains the differences between veterinary and human medications, and emphasizes the importance of vigilance in the drug supply chain to prevent patient harm.Copyright © 2023 International Anesthesia Research Society.
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