Human Factors and Ophthalmic Drug Packaging: Time for a Global Standard

The first death I witnessed in medical school 35 years ago was avoidable. The patient had a cardiac arrest during an otherwise routine angiogram. The anesthesia resident on the crash team intubated the patient and managed the airway while the cardiologists ran the code. Unfortunately, the anesthesia machine in the angiography suite was different from those the resident normally used in the main operating room; the knobs were reversed and labeled differently. When he reached over to turn on the oxygen while holding the endotracheal tube in place before it was taped, the resident delivered pure nitrous oxide instead.