i can't understand what the process was that they were following - how can it be ok to put the saline into an open tray if it's going to be introduced into the spine? it should be drawn directly from a clearly marked vial into the syringe and then into the catheter.

ok, so i'm no anaesthetist obviously - but i've studied medical science in a pathology sense, and you just don't set yourself up for mistakes like this. proper aseptic technique should avoid double/triple handling of anything to ensure it remains sterile at all times - i just can't work out why the saline needed to be decanted into a tray in the first place!

this is just so frikken sad. it was a stupid mistake but people that should have known better - and i agree totally with the recommendations