Tranexamic acid at cesarean delivery: drug-error deaths

Area of Science:

• Obstetrics and Gynecology
• Anesthesiology
• Patient Safety

Background:

• Tranexamic acid is a critical treatment for postpartum hemorrhage (PPH).
• Its use during cesarean delivery, a common site of severe PPH, is increasing.
• Inadvertent intrathecal administration of tranexamic acid instead of local anesthetics has been reported.

Purpose of the Study:

• To highlight the increasing incidence of catastrophic errors involving intrathecal tranexamic acid administration.
• To emphasize the severe neurotoxicity and high mortality associated with this error.
• To propose strategies for preventing these drug errors.

Main Methods:

• Review of reported cases of inadvertent intrathecal tranexamic acid administration.
• Analysis of the neurotoxic effects and mortality associated with this error.
• Evaluation of existing drug safety alerts and recommendations for improvement.

Main Results:

• The incidence of accidental intrathecal tranexamic acid administration appears to be increasing.
• Intrathecal tranexamic acid causes rapid-onset convulsions and has a 50% mortality rate.
• Current drug safety alerts are insufficient to prevent these errors.

Conclusions:

• Enhanced awareness and stringent hospital protocols are essential to prevent intrathecal tranexamic acid administration errors.
• Storing tranexamic acid separately from anesthetic agents, ideally outside the operating room with warning labels, is recommended.
• Large-scale implementation of safety strategies is necessary to mitigate the risk of drug-error mortality and preserve the benefits of tranexamic acid.