Unraveling a recurrent wrong drug-wrong route error—Tranexamic acid in place of bupivacaine: A multistakeholder approach to addressing this important patient safety issue (June 2024)

Summary

This article published by the Anesthesia Patient Safety Foundation looks at a concerning trend in which anaesthetists have inadvertently administered tranexamic acid (TXA) intrathecally when performing neuraxial blocks. The mortality rate of this medication error is approximately 50%. The article examines a case involving a TXA-bupivacaine mix-up, offering perspectives from a multidisciplinary group of contributors. It also provides recommendations to avoid these catastrophic medication errors happening again.