I read with interest the correspondence from Marr et al. [1] regarding their recent drug error, which they attribute to a change in protocol requiring administration of prophylactic antibiotics before surgical incision. The error they describe continues to be the commonest drug error in obstetric anaesthetic practice in the UK [2].

In our unit, we had a similar error 15 years ago, after which we stopped placing general anaesthetic drugs on the anaesthetic worktop during caesarean sections performed under regional anaesthesia, instead keeping them in a separate tray in a fridge, for use only when a general anaesthetic is being administered. Two years ago, however, our most experienced anaesthetic assistant drew up thiopental instead of co-amoxiclav, labelled the syringe as co-amoxiclav and presented it to the anaesthetist with an empty vial of thiopental. The drug was given to the mother, but the error was recognised early and there were no long-term sequelae. All antibiotics are now stored in a separate cupboard in an ante-room.

However, it is unfair for the authors to link their error to the recently published national guidance from the National Institute for Health and Clinical Excellence (NICE) [3]. In the scenario they described, a decision to attempt vaginal delivery had been made before the labelled syringe of thiopental was mistakenly administered, whereas the NICE guidelines recommend the use of antibiotics (although not co-amoxiclav) before surgical incision specifically for patients undergoing caesarean section, rather than vaginal delivery. The drawing up of the wrong drug and at the wrong time are examples of human or protocol errors, and are therefore not attributable to NICE recommendations.


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