Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia

Summary We have reviewed accidental spinal administration of tranexamic acid. We performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. No reports of epidural administration were identified. We identified 21 cases of spin...

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Bibliographic Details
Published in:Anaesthesia 2019-07, Vol.74 (7), p.904-914
Main Authors: Patel, S., Robertson, B., McConachie, I.
Format: Article
Language:English
Subjects:
Acids
anaesthesia, complications
anaesthesia, spinal
Anesthesia
Antifibrinolytic agents
bupivacaine
Catheters
Complications
Fatalities
Human factors
Intravenous administration
Luer
Medical errors
Medical instruments
medication error
Resuscitation
toxicity
tranexamic acid
wrong route error
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Summary:Summary We have reviewed accidental spinal administration of tranexamic acid. We performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. No reports of epidural administration were identified. We identified 21 cases of spinal tranexamic acid administration. Life‐threatening neurological and/or cardiac complications, requiring resuscitation and/or intensive care, occurred in 20 patients; 10 patients died. We used a Human Factors Analysis Classification System model to analyse any contributing factors, and the reports were also assessed using four published recommendations for the reduction in neuraxial drug error. In 20 cases, ampoule error was the cause; in the last case a spinal catheter was mistaken for an intravenous catheter. All were classified as skill‐based errors. Several human factors related to organisational policy; dispensing and storage of drugs and preparation for spinal anaesthesia tasks were present. All errors could have been prevented by implementing the four published recommendations.
ISSN:0003-2409
1365-2044
DOI:10.1111/anae.14662