This double-blind randomised study compared the analgesic efficacy, respiratory effects, side effects, and pharmacokinetic disposition of 24 hr lumbar epidural and intravenous infusions of the same dosage regimen of fentanyl (1.5 #g" kg -t bolus then 1 l~g" kg -I" hr -~ infusion) in 50 patients

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our codes and lables which can be easily read are a necessity. In addition, perhaps it is time for a national body such as the Canadian Anaesthetists' Society to become involved in the problem of packaging-related drug errors in anaesthesia. Finally, it is important to remember that drug labeling and packaging is only part of the complex patient safety issue of getting the right drug to the right patient at the right time by the right route in the right dose. There are many opportunities for human error in all stages of the action of giving a patient a drug 3,4 and any changes made in labeling andpackaging should be done in consultation with the end users.