Adverse events in anaesthesia: the wrong drug.

The first general anaesthetics resulted from the action of one drug, either ether or chloroform. Today, general anaesthetics are usually complex "cocktails" and it is not uncommon for several different drugs to be given. Each of these has a distinct, predictable pharmacological action. Thus, when an unpredicted reaction occurs shortly after the injection of a drug, one possible explanation is that a drug other than the one intended was injected. An example of such a "wrong drug" incident is described in the article in this issue, "An anaesthetic drug error: minimising the risk. "10rser and Oxorn describe the successful management of a critical incident resulting from the accidental intravenous injection of epinephrine instead of glycopyrrolate. Although this article is an anecdotal case report, the paper is important as it illustrates several key points about such incidents.