A threat to patient safety due to drug labelling error in the postanaesthesia care unit during the COVID-19 pandemic

Abstract

A postanaesthesia care unit (PACU) is vital to hospital surgical suites and ambulatory care centres. The COVID-19 pandemic has led to a shortage of trained staff in PACU which lead to opioid drug labelling errors. We report a case of a patient who underwent a loop colostomy for carcinoma rectum under general anaesthesia and then was shifted to PACU for the management of postoperative pain. She received an inadvertently increased dose of injection fentanyl intravenously due to a hand-written labelling error by a junior nurse. But the patient was managed successfully following basic life support protocol.

Keywords

• covid-19
• labelling
• medication error
• postanaesthesia care unit