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Getting into the red: a strategic step for safety
  1. W John Russell
  1. Department of Anaesthesia & Intensive Care, Royal Adelaide Hospital, Adelaide, South Australia 5000

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    In 1993 we examined the first 2000 incident reports using the Australian Incident Monitoring Study (AIMS) and tried to formulate ways of reducing untoward events. One of the major recommendations was aimed at avoiding drug errors.1 There were 144 incidents related to drugs. Of these, 58 incidents were syringe drug swaps and, of these, 71% involved muscle relaxants. This is a classic example of the manager's “80/20 rule” in which 80% of the adverse events will come from about 20% of the drugs. One of the recommended changes was the colour coding of syringes by the drug types they contained. In 1993 there were Standards for Drug Labelling in the USA,2 Canada,3 and South Africa. At the recommendation of the Australian Society of …

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