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Errors in medical practice are not uncommon and may contribute significantly to health care costs and result in harm to patients 1. The risk of serious drug errors in anaesthesia may be higher than other specialties 2. This is hardly surprising, considering that the average anaesthetist administers at least a quarter of a million drugs during a practice lifetime 3. The reported incidence of drug error during anaesthesia varies considerably from 1:133 (0.75%) to 1:5475 (0.02%) 4-7. Differences in study design and data collection may account for some of this discrepancy. Limited data exist for South Africa 8,9. This prospective study was undertaken to determine the incidence of drug administration errors and near-misses at three tertiary-care hospitals in South Africa. Hospitals A and C had predominantly adult patients and Hospital B was a specialist paediatric hospital. MATERIALS AND METHODS The study was approved by the Ethics Committees of the universities to which the hospitals were affiliated. Anaesthetists were asked to complete a study form for every anaesthetic performed during a six-month period. They were asked to indicate whether a drug administration error or near-miss (an incident with * M.B., Ch.B.

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The recent development of multi-lumen catheters that are inserted over a flexible guidewire using a Seldinger technique has revolutionised the insertion of central venous catheters. I As with any new technique it has introduced a problem of its own. We present three cases from our hospital in which the flexible guidewire was inadvertently left inside the catheter. In one instance the guidewire embolised. Case 1 A 60-year-old patient undergoing coronary bypass surgery had an unsuccessful attempt at *F.