Inadvertent Epidural and Intravenous Line Swap: A Case Report

Area of Science:

• Anesthesiology
• Patient Safety
• Pharmacology

Background:

• Medication administration errors, particularly via incorrect routes, pose significant risks of morbidity and mortality.
• Case reports are a primary source of information due to ethical constraints on studying such events.
• Postoperative analgesia following knee arthroplasty often involves multimodal approaches, including patient-controlled epidural analgesia (PCEA) and intravenous medications like acetaminophen.

Observation:

• A 60-65 year old male (ASA III) undergoing knee arthroplasty experienced an accidental misconnection of his intravenous acetaminophen to his epidural line and his PCEA pump to intravenous access.
• The patient, unsupervised, reconfigured the drug lines, leading to ropivacaine being administered intravenously and acetaminophen being infused via the epidural catheter.
• The misconnection went unnoticed for six hours, during which the acetaminophen vial was emptied.

Findings:

• Accidental intravenous-epidural line misconnections can occur due to patient error, leading to unintended drug administration routes.
• The patient received 114 mg of ropivacaine intravenously and the epidural line was exposed to acetaminophen.
• Despite the misconnection, the patient exhibited no abnormal physical findings upon examination by the on-call anesthesiologist.

Implications:

• This incident underscores the critical risks associated with intravenous/epidural line misconnections and the potential for patient error in lower vigilance settings.
• Enhanced safety protocols and system-level improvements are essential to prevent such medication errors.
• The case emphasizes the need for improved patient monitoring and education regarding medical equipment to ensure optimal patient care and safety.