Red plunger syringes for neuromuscular blocking drugs

The recent publication of the 5th National Audit Project (NAP5) into accidental awareness during general anaesthesia (AAGA) once again highlights the potential for drug administration errors to cause patients harm 1-3, noting 17 cases of ‘drug errors and awake paralysis’ (1 in 8 cases of AAGA), of which 11 were as a result of syringe swaps. There are four recommendations at the end of Chapter 13 3. The first two recommendations focus on ampoule design in order to reduce the chance of drawing up the wrong drug, which only accounted for five of the 17 drug errors. The fourth recommendation relates to how to deal with an error. Recommendation 13.3 is the only one that addresses the major issue of syringe swaps and limits itself to saying that anaesthetists should take care when drawing up drugs. The authors have missed an opportunity to make two practical recommendations that are already in the literature. Firstly, the Australian and New Zealand College of Anaesthetists (ANZCA) endorse the use of standardised, colour-coded, user-applied labels in its PS51 Guidelines for the Safe Administration of Injectable Drugs in Anaesthesia 4, as do the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI). The original 1996 ‘Australian Standard’ as quoted in the guidelines has now been adopted as International Standard ISO 26825:2008(E) 5. Secondly, the use of red-plunger syringes for neuromuscular blocking drugs was first suggested in Australia in 1994 and their use is now widespread in Australia and New Zealand 6. The NAP5 authors note that there were no drug errors with propofol and this is thought to relate to its white colour's being instantly recognisable. A syringe with a red plunger, if used solely for neuromuscular blocking drugs, has the potential for anaesthetists to associate a block of red colour with this group of drugs. Whilst standard drug labelling has been endorsed by the RCoA and AAGBI, they have failed to endorse red-plunger syringes for neuromuscular blocking drugs, even though it is nearly a decade since a letter in Anaesthesia called for manufacturers to consider red plungers on pre-filled suxamethonium syringes 7. Has the time come for international anaesthetic colleges and associations to endorse the use of red-plunger syringes for neuromuscular blocking drugs?