Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia (15 April 2019)

Summary

This study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors.

The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.