Preventing drug clutter during emergency intubation; an evaluation of the obstetric emergency drug box

Following a critical incident involving wrong drug administration during a general anaesthetic for an emergency lower segment caesarean section, a prepared box was introduced to each of the obstetric theatres in line with RCOA guidance­. We found that this led to variability in the drugs prepared (dependent on the anaesthetist covering labour ward on a given shift) and whether drugs were drawn up in advance or not. There was also significant wastage, something which has been identified as an issue previously. To reduce this, a standardised list of emergency drugs was agreed, and these would be placed in a designated container (but not drawn up). We then audited this box for adherence to the change, and measured anaesthetists’ opinion regarding this.