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Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.

08:00 EDT 15th April 2019 | BioPortfolio

Summary of "Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia."

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.

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This article was published in the following journal.

Name: Anaesthesia
ISSN: 1365-2044
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Medical and Biotech [MESH] Definitions

A measure of PATIENT SAFETY considering errors or mistakes which result in harm to the patient. They include errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of procedures or the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings and preventable accidents involving patients.

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