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Yimin Cui*

To help prevent drug errors, it is recommended that drugs should be checked with a second person before administration. We aimed to assess the feasibility of introducing second-person or electronic bar-code confirmation of drugs, administered during anaesthesia, in the National Health Service (NHS) settings. Drug errors during anaesthesia remain a serious cause of iatrogenic harm .The white paper ‘Building a safer NHS for patients’9 recommends that ideally, all drug administration should be checked by two qualified practitioners. Several publications suggest that errors can be reduced through double-checking. A review of strategies for preventing drug errors during anaesthesia concluded that double-checking could have prevented 58% of the errors, which made it the most effective single measure. The need to double-check to prevent drug errors during anaesthesia has been strongly emphasized. However, the use of double-checking as a process to reduce drug errors continues to be disputed because of the variability in, and paucity of, rigorous conclusive research evidence of its effectiveness. A recent study concluded that double-checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours learned from psychological research and aviation industry.


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