Medication errors in paediatric anaesthesia: the hidden part of the iceberg

Editor—We read with great interest the recent report by Wahr and colleagues¹ about medication safety in the operating room. The authors highlighted several issues, particularly errors attributable to syringe preparation. Paediatric patients are a population particularly exposed to medication errors owing to the fact that drugs on the pharmaceutical market are, for the most part, supplied in adult packaging and dosage. Thus, the drug dilution procedure is a crucial step to obtain accurate concentrations of drugs used for paediatric or neonatal anaesthesia. As few studies have evaluated the accuracy of drug dilution in the paediatric population, we prospectively assessed the content of syringes prepared by nurse anaesthetists in several paediatric operating theatres in France.

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