• J Shannon and S O'Riain.
• BC Women's Hospital, Vancouver, Canada. drjamesshannon@gmail.com
• Ir J Med Sci. 2009 Sep 1;178(3):291-6.

IntroductionMedication errors are a preventable cause of patient injury. In May 2003, as a result of a joint initiative by the Royal College of Anaesthetists, the Association of Anaesthetists of Great Britain and Ireland, the Intercollegiate Faculty of Accident and Emergency Medicine and the Intensive Care Society, a new colour code chart for syringe labelling was introduced. The introduction of the new system has not been uniform in the Irish Republic with no national guidelines or time scale in place.MethodsA questionnaire was administered to doctors working in Anaesthesia in two Dublin teaching hospitals.ResultsAs much as 23% had administered an incorrect medication and 53% admitted to a near miss as a result of the introduction of the new label.DiscussionFuture action should focus on practical, common sense interventions including techniques such as those that reduce reliance on memory, standardization, the use of protocols and checklists, and the elimination of look-alike products.

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