Setting: Post-operative setting with 2 characters — an anesthesiologist who is standing and another health professional who is seated.
Anesthesiologist: (very agitated as she enters the room) I just finished with that 7-year-old with the appendix. I was going to give him some ondansetron and nearly gave him phenylephrine by mistake. I could have killed that kid!
Colleague: What happened?
Anesthesiologist: I opened the top drawer, reached for a vial, drew it up into the syringe, and checked the vial just before injecting it into the IV. I thought it was ondansetron: it was in the top drawer of the cart where we always keep it. But it was phenylephrine!
I could have killed this kid just because it was in the wrong drawer of the cart. And look! (holds up both vials) I never realized how much alike these two vials are. They're both 2 ml vials with a blue band on the label!
Colleague: Wow, close call!
Anesthesiologist: This can't happen again! If you would have told me before this happened, that someone injected phenylephrine instead of ondansetron, I would have thought it was the anesthesiologist's fault. But I can see now just how easily these things can happen!
Concluding facilitation question: Could this happen where you work?