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Background and Aims The aim of this case is to prevent the accidents that happen in the operating room with the drugs used in anesthesia.Mistakes happened sometimes specially when there is a resemblance between the vials or the ampoules of two or several drugs and because the anesthesiologist do not check(why?- due to his respect and confident to the nurse-anesthetist)the name of the drugs marked on the ampoule opened and handled by the nurse-anesthetist

Methods It is a case of two patients with hip fracture scheduled to be operated for total hip replacement.The patients were females 65 and 72 years old with coronary heart disease hypertension and diabetics 2 type and dyslipidemia.They were well controlled by their medicament The anesthesia consisted of spinal anesthesia with femoral block for post-operative pain management.The first female(65y) received a spinal anesthesia with bupivacaine 0.5% -2 ml hyperbaric with 0.5 ml of morphine sulphate(the vial given accidentally instead of sufentanil ampoule).A femoral block with bupivacaine 0.5%-7ml isobaric was done under ultrasound.The second patient (72y) received the same protocol of anesthesia but with 1 ml of morphine sulfate.

Results The first patient operation went smoothly without hemodynamic complications only a pruritus at the end was settled and took 2 days to resolve.It was treated by dexamethasone 8 mg iv /8h.Naloxone was given at the end of the operation the patient was pain free for 3 days.The second patient collapsed during the operation she was maintained by phenylephrine and sent to the icu then intubated for one day

Conclusions Double checking prevent accident