• Anesthesia and analgesia · Dec 2015

    Review Case Reports

    Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

    A systematic review of 29 published cases of neuraxial obstetric drug errors, including four maternal deaths related to inadvertent intrathecall tranexamic acid.

    What’s the first warning sign of an intrathecal drug error?

    Block failure was the most frequent reported complication.

    What were the most common human factors causing the errors?

    • Similar drug ampoule appearance.
    • Drug storage problems.

    Any recommendations to reduce the risk of drug errors?

    1. Carefully read the ampoule before drawing up, and the syringe label before administering.
    2. Label syringes!
    3. Check labels with a second person or a device.
    4. Use non–luer lock connectors on all neuraxial catheters & devices.
    summary
    • Santosh Patel and Robert Loveridge.
    • From the *Department of Anesthesia, Royal Oldham Hospital, Pennine Acute NHS Trust, Oldham, Greater Manchester, United Kingdom; and †Speciality Trainee, Northwest School of Anesthesia, Northwest Deanery, Manchester, United Kingdom.
    • Anesth. Analg. 2015 Dec 1;121(6):1570-7.

    BackgroundDrug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors.MethodsWe identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice.ResultsTwenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors.ConclusionsThe reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.

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    This article appears in the collection: Inadvertent spinal tranexamic acid: a devastating error.

    Notes

    summary
    1

    A systematic review of 29 published cases of neuraxial obstetric drug errors, including four maternal deaths related to inadvertent intrathecall tranexamic acid.

    What’s the first warning sign of an intrathecal drug error?

    Block failure was the most frequent reported complication.

    What were the most common human factors causing the errors?

    • Similar drug ampoule appearance.
    • Drug storage problems.

    Any recommendations to reduce the risk of drug errors?

    1. Carefully read the ampoule before drawing up, and the syringe label before administering.
    2. Label syringes!
    3. Check labels with a second person or a device.
    4. Use non–luer lock connectors on all neuraxial catheters & devices.
    Daniel Jolley  Daniel Jolley
     
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