Medication error: Subarachnoid injection of tranexamic acid

Area of Science:

• Anesthesiology
• Pharmacology
• Patient Safety

Background:

• Medical errors can stem from factors like ampoule labeling, appearance, and storage.
• Drug mix-ups during anesthesia pose significant patient risks.

Purpose of the Study:

• To report a case of accidental intrathecal injection of tranexamic acid instead of Bupivacaine.
• To discuss the management and outcomes of this medication error.

Main Methods:

• A case report detailing an accidental drug substitution during spinal anesthesia.
• Clinical observation of patient's symptoms, including myoclonus.
• Review of ampoule appearance and identification of the incorrect drug.
• Description of pharmacological and supportive treatments administered.

Main Results:

• Accidental intrathecal injection of tranexamic acid occurred due to similar ampoule appearance.
• Patient developed lower extremity myoclonus post-injection.
• Myoclonus was successfully managed with phenytoin, sodium valproate, and infusions.
• Patient experienced a full recovery with no long-term sequelae.

Conclusions:

• Similarities in drug packaging can lead to critical medication errors in anesthesia.
• Vigilance in drug identification and administration is crucial for patient safety.
• Prompt and appropriate medical intervention can effectively manage adverse drug events.