Tranexamic acid at cesarean delivery: Drug-error deaths

Area of Science:

• Obstetrics and Gynecology
• Anesthesiology
• Patient Safety

Background:

• Tranexamic acid (TXA) is a critical medication for managing postpartum hemorrhage (PPH).
• Its use is expanding globally, including during cesarean deliveries.
• A serious risk has emerged: inadvertent intrathecal administration of TXA.

Purpose of the Study:

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

Main Methods:

• Review of reported cases of inadvertent intrathecal TXA administration.
• Analysis of the neurotoxic effects and mortality associated with TXA.
• Evaluation of current drug safety alerts and recommendations for improvement.

Main Results:

• Identified increasing instances of intrathecal TXA administration instead of local anesthetics for spinal anesthesia.
• Documented profound neurotoxicity, including rapid-onset convulsions and 50% mortality.
• Found existing drug safety alerts insufficient to prevent these errors.

Conclusions:

• Accidental intrathecal TXA administration is a growing and fatal risk.
• Enhanced awareness and stringent hospital protocols are essential for prevention.
• Separate storage of TXA from anesthetics, with clear labeling, is recommended to avert drug-error mortality.