Evidence-based strategies for preventing drug administration errors during anaesthesia

Anaesthesia. 2004 May;59(5):493-504. doi: 10.1111/j.1365-2044.2004.03670.x.


We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Anesthesia, Intravenous / standards
  • Anesthetics, Intravenous / administration & dosage*
  • Drug Labeling / standards
  • Evidence-Based Medicine
  • Humans
  • Medication Errors / prevention & control*
  • Risk Management / methods*


  • Anesthetics, Intravenous