A matter of conscience: a call to action for system improvements involving epidural and spinal catheters.

Anesthesiologists are continually engaged in selfassessment, and our specialty has been defined by its commitment to minimizing errors and ensuring the safety of all patients. Anesthesiologists were pioneers in safety and continue to be seen as leaders in improving quality of care and outcomes. This is well illustrated by the Anesthesia Patient Safety Foundation, which has led efforts in anesthesia-related safety. Notwithstanding this history, 2 related areas of potentially dangerous practice continue despite numerous previous warnings. What are these dangers? The first is the accidental administration of IV drugs into epidural or intrathecal space. The second is the even more dangerous administration of epidural drugs into the circulation via the IV catheter. With this editorial, we challenge the anesthesiology community, along with the relevant industry and regulatory agencies, to take urgent action and eliminate an unnecessary and preventable risk to our patients.