Experience using a new staged extubation kit in patients with a known difficult airway.

The use of technology has certainly been explored and drug identification verification is a targeted area for automation interventions. However, as pointed out, putting a machine in the interaction between patients and doctors does not automatically improve safety. In fact, potential vulnerabilities can be exposed by increasing the complexity of the system as argued by the Normal Accident Theory4. The authors concurred with this. Some of the system issues contributing to drug errors in an operating room cannot be addressed by an automated drug labelling system. These include: • ambient lighting and background noise level, • distractions and interruptions during the drawing up of drugs, • confusion arising from trainees and consultants working together without clear definition of roles leading to omission or doubling up of drug administration and • limitations of technology in dealing with sterile drug administration (e.g. neuraxial routes) where errors lead to more significant consequences. This list could go on. Many aspects of the working environment are recognised to impact on drug administration errors. In addition, there are practitioner factors that are operational at various times. Some examples include fatigue, workload and cognition overload. It is difficult to evaluate the effects of these factors for there has been little success in translating the observations made into measurable indicators of medication safety5. In adopting the Donabedian framework6, the evaluation of using the Codonics Safe Label System to improve labelling compliance of anaesthesia drugs constitutes a processfocused assessment of the quality of care. The difficulties faced with structure measures have already been mentioned. Finally, drug errors are most certainly under-reported, contributed to by drug errors affecting single patients rather than causing mass casualty, the majority of errors not resulting in catastrophic consequences and, in instances where no harm resulted, patients not necessarily even being informed. Without accurate and meaningful data in structure, process and outcome measures, we are challenged in our quest to reduce medication errors during anaesthesia.