Wrong Repackaging and Reconstituted Drug Bank: A Potential cause of Serial Medication Errors: A Case Report

Abstract

Background: Medication error is common in anaesthetic practice. Such errors could result in serial medication errors if reconstituted into a multi-dose bank. This is a report of potential serial medication errors in which suxamethonium could have been administered as vitamin K.

Objective: To highlight the potential risk of medication errors from wrong repackaging and the risk of serial medication errors from reconstitution of drugs into a multi-dose drug bank.

Method: A 3.5kg male baby delivered by Caesarean section (CS)at term, with Apgar scores 8 and 10 developed apnoea following administration of suxamethonium which was reconstituted and labelled as vitamin K by the attending midwife. Full recovery was achieved after manual ventilation using Ambu bag.

Conclusion: A combination of wrong repackaging and reconstitution of drugs into a multi-dose bank is a potential source of serial medication error. Such errors could be averted if appropriate formulations that do not require reconstitution are manufactured by pharmaceutical companies. Same safety regulations before administration of drugs should also apply during repackaging of drugs.

Key words: Wrong repackaging, Reconstituted drug bank, Serial medication errors